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Evaluation of the acceptability of Peer Physical Examination (PPE) in medical and
osteopathic students: an inter-professional cross sectional survey
Fabrizio Consorti1 [email protected]
Rosaria Mancuso1 [email protected]
Annalisa Piccolo1 [email protected]
Giacomo Consorti2 [email protected]
Joseph Zurlo2 [email protected]
1 – Faculty of Medicine and Dentistry, University “Sapienza” of Rome
2 - Centre pour l’Etude, la Recherche et la Diffusion Ostéopathiques of Rome
Contact person:
Fabrizio Consorti
Department of Surgical Sciences
Viale del Policlinico
00161 Rome (Italy)
Abstract
Background
Peer Physical Examination (PPE) is a method of training both in medical and osteopathic
curricula. To obtain comparative information useful for a mutual understanding of the
different professional approaches, the attitudes to PPE were evaluated in two classes of
medical and osteopathic students. The leading hypothesis was that osteopathic students
enter the curriculum with a more positive attitude to the bodily contact.
Methods
A standardized instrument from literature (Examining Fellow Student questionnaire – EFS)
and a new questionnaire were used for a cross-sectional survey in a class of 3rd year
medical student (129) and in two parallel classes of 1st year osteopathic students (112).
Results
The new questionnaire proved to be valid and reliable. Factor analysis identified three
factors (“appropriateness and usefulness”, “sexual implications” and “passive condition”)
accounting for 62.8% of variance. Criterion validity was assessed by correlation with the
EFS (Pearson r coeficent = 0.61). Reliability was expressed as Cronbach's alpha
coefficient= 0.86. The mean score of the questionnaire for medical students was 43.4 ± 8.9
vs 53.4 ± 6.3 for osteopathic students (p<0.01). The only independent variables
significantly predictive of the score at linear regression analysis were sex and the condition
of medical or osteopathic student. The EFS score showed a parallel behavior with that of
the new questionnaire.
Conclusions
These results are compliant with previous research on the process of embodiment both in
medicine and osteopathy. The contact with the body, in the context of PPE, proved to be a
valid topic to promote reflection of teachers and students about own practice and mutual
understanding and acknowledgment between the two professional groups.
Key words: peer physical examination, embodiment, medical student, osteopahic student,
cross sectional survey
Background
Osteopathy is an established recognized system of healthcare which relies on manual
contact for diagnosis and treatment (American Association of Colleges of Osteopathic
Medicine and the American Osteopathic Association, 2005). In Italy, schools of osteopathy
exist since 30 years and osteopathic practice is diffusing, in the context of the
Complementary and Alternative Medicine (CAM).Osteopathy is still in the process of
being acknowledged as an official healthcare profession, and to overcome the lack of a
professional register appointed by the State, the Register of Italian Osteopaths (Registro
degli Osteopati Italiani [ROI], 2010) was constituted, to act as a self-regulatory body for
professional ethics, education and scientific development.
The principles and objectives of osteopathy are not currently taught in Italian medical
curricula and – although both professions acknowledge the value of inter-professional
collaboration (Federazione Nazionale degli Ordini dei Medici, Chirurghi e degli
Odontoiatri[FNOMCeO], 2006; ROI, 2010] – few experiences of integration exist between
Italian osteopathic and medical schools. Inter-professional education (IPE) has been
defined “when two or more professionals learn with, from and about each other to improve
collaboration and the quality of care” (Centre For The Advancement Of Interprofessional
Education [CAIPE], 2002). When the Faculty of Medicine and Dentistry (FMD) of
“Sapienza” University of Rome and the school of osteopathy “Centre pour l’Etude, la
Recherche et la Diffusion Ostéopathiques” (C.E.R.D.O.) of Rome started a scientific and
educational collaboration, learning “about each other” was felt as a priority. So we looked
for an activity involving students and teachers, engaging but not too demanding, pertinent
for both curricula and suitable to provide to students and teachers mutual information
about some relevant aspects of the two professions.
FMD introduced peer physical examination (PPE) some years ago in the curriculum of
“Introduction to Clinical Medicine”. PPE is the learning activity by which students examine
each other and is intended as a way to improve students’ skill avoiding the use of actors or
patients to act as models for physical examination. PPE is also a basic method in
osteopathic schools, to train students in osteopathic manipulative treatment (OMT). A
number of recent studies focused the issue of acceptability of PPE from students of
medical (Reid, Kgakololo, Sutherland, Elliott, & Dodds, 2012), nursing (Wearn,
Bhoopatkar, Mathew, & Stewart, 2012) and physiotherapy schools (Delany & Frawley,
2012), but even the latest published review could not find research about inter-professional
comparison (Hendry, 2012).
The objective of this study was then to measure the attitude to PPE in two groups of
medical and osteopathic students to obtain comparative information useful for a mutual
understanding of the different professional approaches. The leading hypothesis was that
osteopathic students enter the curriculum with a more positive attitude to the bodily
contact. The study was also aimed to confirm the findings of previous research about PPE
in a large group of Italian healthcare students, since no previous studies exist in Italian or –
at large – in European Latin students.
Methods
FMD runs a discipline-based medical curriculum 6-year long. After the first two years of
pre-clinical basic sciences, students approach clinical subjects at the third year in the
curriculum of “Introduction to clinical medicine”, where PPE is used to train their skill in
physical examination. CERDO runs a 6-year long curriculum in osteopathy, conformant to
ROI standard. The school offers a full-time curriculum for lay students and a part-time
curriculum for medical doctors and physiotherapists. PPE is introduced since the first year,
as preferred method to train both diagnostic palpation and OMT.
For the aims of this study we did a cross sectional survey in a class of 3rd year medical
student (129) and in two parallel classes of 1st year osteopathic students of the full and
part time curriculum (112). The survey was done in the academic year 2011-12, just after
the students’ first experience of PPE. Demographics and relevant cultural data of the
sample are presented in Table 1.
The study had ethical approval from both schools. Data were collected in an anonymous
format, with students’ oral consent. No selection criteria were applied and there was no
sampling, since the whole classes were surveyed.
Validation of the instrument and statistical methods
To measure acceptability of PPE we used both Examining Fellow Student (EFS)
questionnaire (Rees, Bradley, & McLachlan, 2004) and a new questionnaire we developed
to gain a deeper understanding of the elements composing the overall construct of
acceptability of PPE. EFS in fact explores the overall acceptability of doing and undergoing
PPE for different body regions, without any other consideration of possible different
dimensions of the construct. Our questionnaire was designed to measure two different
although related elements, on a five grade Likert scale (0: completely disagree, 4:
completely agree):
- the acceptability of the practice of PPE, explored in different contexts and potentially
problematic situations (active or passive role, exposure of the body, fear of sexual interest,
relationship with partners of the same or opposite gender and with the tutor: items from 1
to 11)
- the students’ opinion on the educational value of the PPE (items from 12 to 16)
The items were scored according to the selected grade, except for items from 3 to 7 and
12, which were scored in a reverse way. The maximum possible score was 64 points.
The questionnaire asked some other questions about students’ preference for
organizational topics (formation of working groups, written protocol of conduct) and about
personal and cultural data..
The questionnaire had been previously validated in a group of medical students [Consorti,
Mancuso, Milazzo, Notarangelo,& Piccolo, A., 2012), but in this larger sample of students
we assessed construct validity by principal components factor analysis and criterion
validity by comparison with the EFS score. Table 2 lists the items and shows the result of
factor analysis, which identified three factors with an eigenvalue>1, that were interpreted
as “appropriateness and usefulness”, “sexual implications” and “passive condition”. These
three factors accounted for 62.8% of variance.
The Pearson r coefficient between the score of the questionnaire and the score of EFS
was 0.61, expressing a good correlation. Reliability was assessed according to classical
item analysis by Cronbach's alpha coefficient. The instrument showed an acceptable value
of 0.86.
Comparison of the mean scores for stratified subgroups was performed by two-tailed
Student t-test for unpaired samples, with an acceptable alpha error <0.05; correlation of
personal and cultural data with the score of the questionnaire as a dependent outcome
variable was analyzed with multivariate linear regression. All statistical calculations were
made with Statistica software.
Results
The mean score for medical students was 43.4 ± 8.9 vs 53.4 ± 6.3 for osteopathic students
(p<0.01). The difference was significant both with the full time (51.07 ± 5.6) and the part
time (54.28 ± 6.21) group. The difference between the two groups of osteopathic students
was significant as well (p<0.05). In the mean, PPE was acceptable for the whole sample,
with only 3% of students scoring the two lowest grades at the first item (active role, all
medical students) and 12% at the second item (passive role, only 1 osteopathic student).
Nevertheless, when the students were asked if PPE was an appropriate practice (items 13
and 14), the lowest grades decreased to 1 student for active role and 4% for passive role.
Overall, women marked a lower score than men (f: 45.5 ± 9.3 vs m: 51.1 ± 8.2; p<0.01).
This difference was present in the medical students’ group (f: 42.05 ± 8.5 vs m: 46.3 ± 9.3;
p<0.02) but was not observed in the osteopathic students’ group (f: 52.6 ± 6.7 vs m: 53.9
±6.0; n.s.).
The score showed only a weak correlation with age (Pearson r = 0.26) in the group of
osteopathic students. No significant difference of score was observed between subgroups
stratified for declared religious belief and for the Italian area of origin in any of the classes.
The EFS score showed a parallel behavior with that of our questionnaire. Table 3 and 4
summarize the results more in details.
The only independent variables significantly predictive of the score at linear regression
analysis were sex and the condition of medical or osteopathic student. The best predictive
model accounted for 34% of variance (R2= 0.34 - Table 5).
Discussion
Our study confirmed the hypothesis that osteopathic students approach their curriculum
with a stronger attitude to the bodily contact and that this difference is not explained by any
of the demographic and social –cultural variables we considered. This finding is consistent
with previous empirical research about body work in CAM and the disembodiment process
in medical examination.
The expression ‘body work’ refers to an employment sector with the involvement of
distinctive and often intimate relation with the bodies of consumers, clients or patients
(Wolkowitz, 2006). In his ethnographic research in a school of Osteopathy, Gale (2011)
described the concept of ‘body talk’ as the way in which the embodied patient is able to
communicate with the practitioner, not only through verbal interaction but mainly through a
‘dialogue with the tissues’ during diagnostic palpation and through physical appearance at
direct observation. Gale highlighted ‘the centrality of embodied interaction at the
investigative stage of the osteopathic healing process’.
In a set of case studies, Young (1989) examined the phenomenology of the body during a
medical examination, arguing that the body is ‘reframed to exclude some of its symbolic
properties, especially sexual ones’. Moreover, the body is transformed into an object of
scrutiny, in the context of the social contract upon which medical act relies. The dual
attention to the body as incarnate and disincarnate is handled by a delicate ‘etiquette of
touch’.
In the frame of these assumptions, it is not surprising that the reactions of the students of
medicine and osteopathy to a training simulation like PPE were different, both with respect
to the active contact with a fellow’s body and to the passive contact on own body, because
the social expectations about their profession they perceive when entering their curricula
are probably different. In a qualitative analysis of students’ comments about PPE, in the
light of Engeström model of activity theory (Wearn, Rees, Bradley, & Vnuk 2008), the
authors noted that the students clearly differentiated between the peer examiner-examinee
relationship and the doctor-patient relationship. PPE blurred interpersonal boundaries in
an unexpected way, producing ambiguities. Apparently, this is less true for osteopathic
students, who in ‘learning to interact with the bodies of their patients, develop a new
orientation to their own bodies’ (Gale, 2011) and are probably more prone to inter-
subjectivity.
Female medical students were more concerned about PPE than men, similarly to what
already found by other researchers (Rees, Wearn, Vnuk, & Sato, 2009; Rees, Bradley,
Collett, & McLachlan, 2005; Chen, Yip, Lam, & Patil, 2011; Wearn & Bhoopatkar, 2006).
This difference of gender was not evident in osteopathic students, even if female students
of the full time osteopathic curriculum - which in our sample were younger of their
colleagues of the part time curriculum and as old as medical students - tended to show a
slightly weaker attitude than men. In her analysis of PPE according to the feminist theory,
Rees (2007) stated that older women are usually more uncomfortable with PPE than
younger women. This statement is apparently in disagreement with our results, but Rees
explained the concern of older women because they unfavourably compare with younger
women. This was not the case in our groups, which were rather uniform as to age,
avoiding a possibly unpleasant comparison. The difference in mean age and the condition
of being already registered professionals (doctors or physiotherapists) can be possible
explanations for the difference observed between full and part time osteopathic students.
Our questionnaire proved to be valid and reliable. Factor analysis showed high factor
loadings and suggested a structure of the construct slightly different from what we thought
in designing the instrument. The two components of general attitude and perceived
educational value went together in the first factor, while two other rather independent
components emerged, connected with sexual issues and the passive condition of
exposition of own body. The first factor was somehow expected, the latter can be
connected to what other researches (McLachlan, White, Donnelly, & Patten 2010) denoted
as embarrassment (from a student’s interview: ‘I just think I’m embarrassed about my body
image, my body and people seeing it’), a construct which is not directly linked to sexual
contents but rather to the cultural image of the body.
As a last point we did not observe a strong influence by cultural factors like religious belief
and geographic area of origin, differently from what found by others (Rees, 2009).
Believers scored slightly lower than non-believers, but the difference was not significant.
All believers students were Roman Catholic and, despite the strong influence Catholic
church had on its history, Italy is now a laic country. Italy is quickly becoming a multiethnic
country (Italian Institute of Statistics, 2012) and maybe in the future, with the increase of
students of other religions the situation could change. We expected a lower attitude to
PPE from students coming from southern regions, because the south of Italy is believed to
be more linked to a traditional image of modesty, but our data excluded this hypothesis.
The main limitation of this study is its being based on a convenience sample, introducing a
possible bias and limiting the possibility of fully exploring some of the variables, such as
the geographic origin. The only 4 students coming from the north of Italy could not be
considered a valid sub—group for analysis. The absence of a sampling strategy prevented
also a correct computation of the dimension of the sample. Hence some conclusions,
specially about the absence of effect, must be taken cautiously. More robust conclusions
could be driven from a larger, multi-centric, nation-wide study.
Conclusions
It has been stated that interprofessional education relies on the three main content areas
of interprofessional collaborative patient-centered practice, teaching and learning, and
leadership and organizational change (Steinert, 2005). FMD and CERDO started their
cooperation with the comparative evaluation of a teaching/learning activity that we thought
was able to give some information about the inner nature of the two professional
processes of allopathic medicine and osteopathy. The contact with the body, in the context
of PPE, proved to be a valid topic to this aim, and the result of this study contributed to the
reflection of teachers and students about own practice and to mutual understanding and
acknowledgement. The experience of collaboration of the two schools in this project forms
a strong base for further joint learning and research activities, aimed to provide guidelines
and scientific evidence to collaborative patient-centered practice.
Overall PPE was acceptable both by medical and osteopathic students, even if to a
different extent. Although 12% of medical students felt embarassed in undergoing PPE,
only 4% considered it inappropriate.There is still much debate about whether PPE should
be a mandatory or elective learning activity [Rizan, Shapcott, Nicolson, & Mason, 2012;
Outram & Nair, 2008). Our data showed that there are not strong constraints to PPE in our
sample of Italian students, but that this activity should be anyway carefully designed and
introduced before being implemented. The construct of acceptability of PPE can also give
useful information for counseling students with respect to their future professional choices,
addressing students with low scores to a path of personal inquiries about their relationship
with the body or toward specialties without contact.
Competing interests The Authors declare that they have no competing interests with respect to the content of
this article.
Authors’ contribution
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Table 1 – Demographics and social-cultural characteristics of the sample
No. Sex (%)
Age (mean ± s.d.)
Religious belief (%)
Geographic area (%)
Medical students 129 m: 42 (32.6) f: 87 (67.4)
22,1 ± 3.4 y: 75 (58.2) n: 54 (41.8)
north: 1 (0.8) centre: 84 (65.1) south: 44 (34.1)
Full time osteopathic students
30 m: 21 (70) f: 9 (30)
22,6 ± 6.7 y: 20 (66.6) n: 10 (33.4)
north: 0 (0) centre: 23 (76.7) south: 7 (23.3)
Part time osteopathic students
82 m: 48 (58.5) f: 34 (41.5)
28,7 ± 6.7 y: 54 (65.9) n: 28 (34.1)
north: 3 (3.7) centre: 58 (70.7) south: 21 (25.6)
Total 241 m:111(46.1) f:130 (53.9)
24,4 ± 6,0 y:149 (61,8) n: 92 (38,2)
north: 4 (1.6) centre:165 (68.5) south: 72 (29.9)
Table 2 – Factor analysis of the questionnaire. Factor Loadings (Varimax normalized) Extraction: Principal components (Marked loadings are >,450000) Factor Loadings (Varimax normalized) Extraction: Principal components (Marked loadings are >,450000)
ITEMS Factor1
Factor 2
Factor 3
1. In general, I feel comfortable when performing PPE on a colleague of mine 0,64 -0,10 0,52 2. In general, I feel comfortable when a colleague performs PPE on me 0,57 -0,06 0,63 3. I feel embarrassed if I am undressed for PPE in front of my group of
colleagues 0,13 0,11 0,82
4. I feel embarrassed if I am undressed for PPE in front of my teacher or tutor 0,26 0,12 0,82 5. I am concerned of being a possible object of sexual interest during PPE -0,08 0,60 0,45 6. I am concerned of experiencing possible sexual interest for my colleagues
during PPE -0,02 0,79 -0,05
7. I am concerned of experiencing possible sexual interest for my teacher or tutor during PPE
0,22 0,73 -0,07
8. I feel comfortable when performing PPE on a colleague of my same sex 0,66 0,06 0,16 9. I feel comfortable when performing PPE on a colleague of the opposite sex
than mine 0,68 -0,04 0,39
10. I feel comfortable when PPE is performed on me by a colleague of my same sex
0,68 0,01 0,34
11. I feel comfortable when PPE is performed on me by a colleague of the opposite sex than mine
0,59 -0,06 0,57
12. It is inappropriate to perform PPE on persons that will be my future colleagues
0,17 0,75 0,12
13. To perform PPE is an appropriate practice for the education of a medical doctor (osteopath)
0,75 0,22 -0,08
14. To undergo PPE is an appropriate practice for the education of a medical doctor (osteopath)
0,78 0,11 0,17
15. In performing PPE I get useful feed back from my colleagues about my skill 0,74 0,18 0,09 16. It is a sign of professionalism as a student to accept to perform and
undergo PPE 0,67 0,09 0,17
Expl.Var 0,30 0,14 0,18
Table 3 – Score of the questionnaire (mean ± standard deviation) for type of school, sex, religious belief and geographic area of origin. Maximun theoretical score= 64
Score
Sex
Religious belief
Geographic area (a)
Medical st.
43.40 ± 8.9 1 m: 46.35 ± 9.33 f : 42.05 ± 8.5
y: 42.84 ± 9.5 4 n: 44.09 ± 8.1
centre: 43.80 ± 9.64 south: 43.04 ± 7.7
Full time osteopathic st.
51.06 ± 5.61,2 m: 52.14 ± 4.74 f : 48.55 ± 7.1
y: 50.65 ± 4.7 4 n: 51.90 ± 7.3
centre: 51.30 ± 5.94 south: 52.00 ± 3.1
Part time osteopathic st.
54.28 ± 6.31 m: 54.68 ± 6.34 f : 53.70 ± 6.3
y: 53.81 ± 6.8 4 n: 55.33 ± 5.3
centre: 54.91 ± 5.34 south: 53.76 ± 6.8
All osteopathic st.
53.42 ± 6.31 m: 53.91 ± 6.04 f : 52.63 ± 6.7
y: 52.95 ± 6.4 4 n: 54.40 ± 6.0
centre: 53.81 ± 5.74 south: 53.32 ± 6.0
(a) –four students coming from northern regions were excluded from the analysis due to the low number, 10 missing values 1: medical vs all osteopathic st. p< 0.01; 2: full time vs part time osteopathic st. p<0.05 ; 3: p<0.05; 4:n.s.
Table 4 – EFS score (mean ± standard deviation) for type of school, sex, religious belief and geographic area of origin. Maximum theoretical score= 52
Score
Sex
Religious belief
Geographic area (a)
Medical st. (129)
27.85 ± 4.31 m: 29.56 ± 4.51 f : 27.05 ± 4.11
y: 27.81 ± 4.42 n: 27.83 ± 4.3
centre: 27.60 ± 4.62 south: 28.39 ± 3.7
Full time osteopathic st.
30.27 ± 2.61,2 m: 30.85 ± 2.01 f : 28.88 ± 3.31
y: 30.75 ± 2.12 n: 29.30 ±3.2
centre: 29.90 ± 2.82 south: 31.38 ± 1.9
Part time osteopathic st.
30.96 ± 3.01,2 m: 31.22 ± 2.72 f : 30.58 ± 3.32
y: 30.88 ± 2.92 n: 31.08 ± 3.3
centre: 30.62 ± 3.62 south: 31.66 ± 1.0
All osteopathic st.
30.76 ± 2.9 1 m: 31.11±2.522 f : 30.20 ± 3.32
y: 30.84 ± 2.62 n: 30.57 ± 3.3
centre: 30.39 ± 3.42 south: 31.57 ± 1.2
(a) –four students coming from northern regions were excluded from the analysis due to the low number, 10 missing values 1: p< 0.01; 2: n.s.
Table 5 – Linear regression model for the score of questionnaire as dependent variable
Variable Coefficient St. Error p
Intercept 31,24 2,70
Sex (f) 3.06 1,1 < 0,01
School (osteopathy)
9,60 1,10 < 0,01
Geographic area (centre)
0,45 0,92 n.s.
Religious be lief (y) -1,30 1,07 n.s.