Medical schools around the world often use peer physical examinations (PPEs), which involve students physically examining each other for educational purposes under the direction of a supervisor (e.g. clinician, tutor and academic staff member), as part of clinical skills training. During PPEs, one student usually assumes the ‘doctor’ role and carries out the physical examination (i.e. the doctor student) whereas another student assumes the ‘patient’ role and is physically examined (i.e. the patient student). These examinations are restricted to non-intimate body regions according to Western customs only. Models or simulated patients are commonly used for intimate examinations (e.g. digital rectal examination). There are many advantages for conducting PPEs such as the following:

  • PPEs enable students to study normal anatomy prior to learning abnormality [1].

  • PPEs enable students to learn what it feels like to be examined (i.e. obtain a patient’s perspective) [2–4].

  • PPEs enable students to improve their technique by practising the same examination multiple times on the same individual which is often not possible when examining real patients.

  • PPEs enable students to obtain peer feedback to improve their examination technique [5].

  • PPEs enable students to practise in a safe environment [4].

  • PPEs are easy to organise and cost efficient [1, 4].

However, despite the many advantages PPEs offer, unexpected events may arise in PPEs such as the following:

  • The discovery of an abnormality or circumstance requiring further investigation in a student [1, 6, 7]

  • Inappropriate behaviour by some students [2, 8]

  • Breaches in confidentiality regarding information that was revealed during a PPE

Thus, these unexpected events need to be managed efficiently via establishing and enforcing a PPE policy and an associated procedure. However, currently, no Australian medical school has a PPE policy and associated procedure [9]. Thus, the aim of this paper is to propose information to be included in a PPE policy and an accompanying procedure which sets out how to comply with the policy.

PPE Policy Development

Australian medical schools should develop and implement a PPE policy that is applicable to all staff involved in teaching clinical skills (from here on referred to as ‘supervisors’) and students.

Bachelor of Medicine/Bachelor of Surgery students must be proficient in physical examination as stated in the Australian Medical Council [10]. Therefore, the proposed policy must reflect this by stating that all medical students must physically examine peers as part of their training.

Unlike the requirement to examine peers, students do not need to act as patients. Some students may not wish to be examined for various reasons such as religious observations, childhood abuse or body image concerns [4, 8]. Information must be included in the policy stating that students do not need to volunteer themselves to be examined (i.e. be a patient), that students cannot be coerced to be physically examined, that students’ refusal to take on the patient role must be respected and they do not need to disclose their reasons.

The issue of consent to be physically examined must also be addressed in the policy. Ideally, written consent should be obtained from all students at the beginning of each academic year that includes PPEs. In addition to obtaining written consent at the commencement of an academic year, verbal consent must be obtained prior to each examination (e.g. ‘is it ok if I examine your knee?’). Furthermore, the policy must also stress that consent can be withdrawn at any time and without reason.

Confidentiality is another component that must be part of the PPE policy. Students and supervisors must keep all information obtained as a consequence of engaging in PPE confidential.

In accordance with the requirement that doctors must practice medicine in a professional manner, professionalism in terms of inappropriate behaviour not being tolerated during PPEs must also form part of the PPE policy.

Given that abnormalities or circumstances requiring further investigation may arise during PPEs, the PPE policy must state that students are responsible for seeking independent professional medical advice. It is not the supervisor’s responsibility, irrespective of their training, to provide students with medical advice. The supervisor should ideally confirm the presence of an abnormality/circumstance requiring further investigation detected by a peer and if confirmed, advise the student to seek independent professional medical advice.

The policy must also state that supervisors take reasonable steps to ensure that all students feel safe and comfortable when engaging in PPEs (e.g. avoid intimate areas to be examined and provide examination screens). Furthermore, supervisors must ensure that unexpected circumstances arising during PPEs are investigated promptly, confidentially and impartially.

In conclusion, the PPE policy should be accompanied with a PPE procedure that sets out how to comply with the PPE policy.

PPE Procedure Development

The PPE procedure accompanying the PPE policy should detail how to address unforeseen circumstances/issues arising during physical examinations. Areas that need particular attention include finding an abnormality, inappropriate behaviour, a breach in confidentiality and students not wishing to examine others.

Finding an Abnormality

During PPEs, the doctor student may detect an abnormality or a circumstance requiring further investigation in the patient student. Abnormal findings or circumstances requiring further investigation include detecting an abnormal mass or lump, a heart murmur or abnormally high blood pressure. How a PPE procedure could be used if an abnormality is detected will now be outlined using a case example.

Case Example

Situation

During a PPE session during his second year of medicine, Cameron takes Vanessa’s blood pressure and notices it is extremely high. He repeats the procedure and obtains the same high reading.

How Procedure Would Be Used

Following the PPE procedure for detecting an abnormality (see Fig. 1), Cameron confidentially informs Vanessa of her abnormally high blood pressure and asks if she is aware of this. Vanessa indicates that she was unaware of her abnormally high blood pressure. Both students confidentially inform their supervisor, Dr. Laws. Dr. Laws asks Vanessa if she can take her blood pressure and Vanessa consents. Dr. Laws also detects that Vanessa has high blood pressure, informs Vanessa of this, and recommends that she seeks independent professional medical advice. Dr. Laws stresses that this is her responsibility. Vanessa and Dr. Laws complete a confidential form, signed by both parties, to acknowledge that an abnormality was found and that Vanessa understands that it is her responsibility to seek independent medical advice. Dr. Laws informs Cameron that his findings were verified.

Fig. 1
figure 1

Flowchart showing the procedure to be followed by the ‘doctor’ student, ‘patient’ student and supervisor for the discovery of an abnormality or circumstance requiring further investigation

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Inappropriate Behaviour

There are many form of inappropriate behaviour such as students deliberately using medical equipment for purposes it is not designed for, students sexually abusing another student and students making derogatory or offensive verbal remarks. Supervisors can become aware of inappropriate behaviour by either directly witnessing the behaviour themselves or being alerted to it by others. The consequences of inappropriate behaviour must be addressed on a case by case basis given the wide variety of inappropriate behaviours that can take place, the severity of the nature of the incident and whether the student is a repeat offender. How a PPE procedure could be used if inappropriate behaviour takes place will now be outlined using a case example.

Case Example

Situation

During a PPE session in his first year of medicine, Robert makes an anti-semitic remark. His supervisor, Dr. Jones, and fellow first year medical students including Daniel, who is Jewish, hear this remark. Daniel is deeply offended by the remark.

How Procedure Would Be Used

Following the PPE procedure for inappropriate behaviour (see Fig. 2), Dr. Jones takes Robert aside and informs him that his behaviour was inappropriate. Dr. Jones makes the decision that the behaviour does not warrant immediate exclusion from PPE and establishes that this is the first time Robert has behaved in this manner. Dr. Jones meets with Daniel alone and asks what he thinks would be a suitable punishment for Robert. They mutually agree that Robert needs to formally apologise to Daniel, accompany him to the Holocaust Museum and write a reflection on his behaviour in light of his visit to the museum. Dr. Jones informs Daniel of counselling services available. Lastly, Dr. Jones formally records the incident in a confidential database kept within the school and informs Robert that his behaviour has been recorded.

Fig. 2
figure 2

Flowchart showing the procedure to be followed by the supervisor for inappropriate behaviour

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Breach in Confidentiality

During PPEs, confidential information can be revealed during history taking (e.g. students revealing a history of medical problems) or as a direct consequence of a physical examination (e.g. noticing scars normally concealed by clothing and enlarged organs determined via palpation). Despite confidentiality being stressed, breaches in confidentiality sometimes arise. Such breaches in confidentiality must be addressed as it is crucial that students learn to keep information confidential. How a PPE procedure could be used if there is a breach in confidentiality will now be outlined using a case example.

Case Example

Situation

As part of a PPE session, Matthew reveals to Garry that he has had hepatitis in the past. Matthew has not revealed this to any of his peers before. Later that day Garry tells several of his medical student friends that Matthew has had hepatitis in the past. The next day, Matthew overhears some of Garry’s friends discussing his hepatitis. Matthew reports the breach in confidentiality to his supervisor, Professor Hayes.

How the Procedure Would Be Used

Following the PPE procedure for a breach in confidentiality (see Fig. 3), Professor Hayes confidentially arranges a meeting with Garry and informs him that sharing confidential information pertaining to Matthew’s medical history is unacceptable and a breach of the university’s policy. Through the conversation, she establishes that this is the first time Garry has breached confidentiality. Garry’s claims are supported by the school having no record of inappropriate actions during clinical skills training. Professor Hayes requests Garry to formally apologise to Matthew and to complete a reflective piece on the importance of maintaining confidentiality. Additionally, Professor Hayes meets with Garry’s friends to ensure that there are no further breaches in confidentiality and that they must maintain all information they unintentionally received from Garry confidential. Professor Hayes ensures that Matthew is aware of all counselling services available to him. The incident is formally recorded on the school’s confidential database and Garry is made aware of this.

Fig. 3
figure 3

Flowchart showing the procedure to be followed by the supervisor for a breach in confidentiality

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Students Not Wishing to Examine Peers

During PPEs, it is possible that some students will refuse to physically examine peers. Supervisors must discretely approach these students and establish why the student is not participating. Some students may have a legitimate reason for not taking part for a short period of time (e.g. physical injury making it difficult to examine or a viral infection and thus minimising contact with others). Students not having a valid reason for not taking part are to be reminded of the expectation to examine peers in order to become competent in physically examining patients. How a PPE procedure could be used if a student refuses to physically examine peers will now be outlined using a case example.

Case Example

Situation

Professor Brown notices Natalie, a first year medical student, sitting in the corner and not taking part in examining her peers.

How the Procedure Would Be Used

Following the PPE policy and procedure, Professor Brown discretely takes Natalie aside and asks her as to why she is not taking part in examining her peers. Natalie informs Professor Brown that she sprained her wrist during a fall while playing netball the previous evening and thus has difficulty conducting a physical examination. Professor Brown suggests that Natalie should assist her peers conducting a physical examination through conversation given that she cannot physically participate at present. Furthermore, Professor Brown informs Natalie that she must fully participate again once her wrist has recovered given that she is expected to be competent in physically examining a patient. Professor Brown asks Natalie to perform the examinations she was unable to practise in a subsequent class once her injury has healed.

Discussion

We anticipate that the ideas suggested here for content to be contained in a PPE policy and procedure, in addition to how such a policy and procedure could be used, will assist Australian medical schools to formulate a PPE policy and accompanying procedure. Furthermore, given that PPEs are used by medical schools around the world, we believe that the ideas proposed would also be applicable to medical school outside of Australia for two main reasons: (1) Australia is a multicultural country and thus educators within Australia are cognisant of cultural sensitivities, and (2) the issues covered here are not unique to Australia and/or associated with cultural differences (e.g. the discovery of an abnormality). In regards to developing the actual policy, we believe that both staff and students should be actively involved in the process so that both parties will have a sense of ownership of the policy which in turn will improve adherence to the policy. Once developed, such a policy and procedure must be formally implemented and evaluated. Each university will have their own departments for creating new policies and accompanying procedures that need to be followed. The use of such a PPE policy and accompanying procedure may also be adopted by other schools (e.g. anatomy, nursing, podiatry, sport and exercise science) where physical contact between students is a requirement of the course.

Whilst the potential issues arising during PPEs discussed within this paper appear quite simplistic on face value and the procedures to follow appear obvious, it must be kept in mind that the consequences of not following these could lead to major consequences for students and/or educators concerned. Thus, we believe that it is essential that all medical schools develop and implement a formal written PPE policy and accompanying procedure.