Evaluation of the acceptability of Peer Physical Examination (PPE) in medical and

osteopathic students: an inter-professional cross sectional survey

Fabrizio Consorti1 fabrizio.consorti@uniroma1.it

Rosaria Mancuso1 rosaria_mancuso1987@libero.it

Annalisa Piccolo1 annalisa.piccolo@yahoo.it

Giacomo Consorti2 giacomo.consorti@gmail.com

Joseph Zurlo2 joseph.zurlo@gmail.com

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)

fabrizio.consorti@uniroma1.it

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.