Students’ concernsabout examining theirpeersLorna Mary Gibson, Fifth Year Medical Student, University of Edinburgh, UK

Wearn AM, Rees CE, Bradley P, Vnuk AK.

Understanding student concerns about

peer physical examination using an

activity theory framework. Med Educ

2008: 42: 1218–1226

Medical students are con-cerned that it is difficult tomaintain professionalism duringpeer physical examinations (PPE),which are used to facilitate thelearning of clinical examinationskills.

Researchers from FlindersUniversity and the Universitiesof Exeter, Plymouth, Aucklandand Sydney conducted a quali-tative study of medical students’attitudes to PPE usingquestionnaires. Medical students

from six different schools acrossfive countries (UK, Australia,New Zealand, Hong Kong andJapan) completed aquestionnaire at the start, andanother at the end, of their firstyear.

The researchers asked stu-dents for their general viewsabout examining their peers,plus their concerns about exam-ining and being examined byother students. The authorsindependently identified preli-minary themes from students’responses before constructing aframework to code the data.Three sub-themes emergedrelating to possible barriers toPPE.

RELATIONSHIPS

Students contrasted their peerrelationships with doctor–patientrelationships, explaining that theinformal nature of peer relation-ships made it difficult to maintainprofessionalism during PPE.

EXAMINATION ISSUES

Students were concerned abouthurting their peers, but consid-ered that it was better to learn byexamining peers than byexamining patients.

PROCESS AND STRUCTURE

Students thought that peerexaminations were artificial, as

Medicalstudents areconcerned thatit is difficult tomaintainprofessionalismduring peerphysicalexaminations

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they were non-confidential anddisrespectful compared withdoctor–patient interactions, andbecause examinees were perceivedto be ‘healthy’, and anticipatedthe next part of the examinationsequence in contrast withpatients.

The authors discussed theirfindings in the context of activitytheory, which considers interact-

ing influences within an activitysystem, such as rules that governthe behaviour of participants inan activity. They concluded thatdifferent rules govern the doctor–patient and the PPE activitysystems, and that the informalnature of peer relationships mayallow lapses of professionalism,leading to breaches ofconfidentiality and disrespectfulbehaviour.

Objectives are another inter-active influence that differbetween the PPE and the doctor–patient activity systems, as thePPE aims to facilitate the learningof examination skills, whereas aclinical examination aims to aiddiagnosis. The authors weretherefore not surprised thatstudents thought that PPE wasan artificial process, given thatstudents were not aiming to makea diagnosis.

The authors acknowledge thatusing questionnaires rather thaninterviews to collect qualitativedata on students’ concerns aboutPPE has limited their study.However, using questionnairesallowed data to be collected from617 out of 784 students.Although the authors brieflydiscuss that some students hadthe differing view that PPE mayallow them to develop profes-sionalism, it is not clear howmany students shared theconcerns presented by theauthors, or whether differencesexisted in the concerns ofstudents from different countries.

The authors recommend thatguidance should be developed forstudents who participate in PPE,given the students’ concernsabout lapses in professionalbehaviour. Further research usingobservational studies and inter-views is recommended to examinehow the PPE activity systeminteracts with the student–patient activity system, whenstudents develop theirexamination skills further byexamining patients.

The informalnature of peer

relationshipsmay allowlapses of

professionalism

206 � Blackwell Publishing Ltd 2009. THE CLINICAL TEACHER 2009; 6: 205–206