Rheumatology Advance Access originally published online on April 13, 2006
Rheumatology 2006 45(11):1404-1408; doi:10.1093/rheumatology/kel126
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Undergraduate musculoskeletal examination teaching by trained patient educators—a comparison with doctor-led teaching
Rheumatology, Derbyshire Royal Infirmary, Derby, East Midlands and 1Postgraduate Dental and Medical Education School of Community and Health Sciences, University of Nottingham, Nottingham, East Midlands, United Kingdom.
Correspondence to: Nicholas Raj. E-mail: nicholas.raj{at}nhs.net
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Abstract |
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Background. To compare the core hand and knee examination skills gained by undergraduates taught either by trained patient educators (PEs) or by doctors.
Methods. A total of 50 final year medical students were randomized to receive training from PEs or doctors. Group A were taught hand examination by a PE with rheumatoid arthritis, and knee examination by a PE with osteoarthritis. Group B was taught hand and knee examination by a consultant rheumatologist plus an untrained patient with appropriate signs. All students were taught an established core skills set in small group workshops. Students then undertook two validated objective structured clinical examination (OSCE) stations with two blinded assessors. Pre- and post-teaching questionnaires established the students’ self-reported levels of skills (SRS) and a student evaluation of teaching (SET). The study was analysed as an equivalence trial. A mean difference in OSCE scores of 10% was assumed to be of educational significance.
Results. Although the SET scores of both groups were high, the doctor-led group received higher scores. Aside from this, the two student groups did not differ significantly. There were no significant differences in mean hand OSCE (mean difference = 0.88, P = 0.28, 95% CI = –0.73 to 2.49) or knee OSCE (mean difference = 0.28, P = 0.7, 95% CI = –1.19 to 1.75) scores. Both the upper and lower confidence intervals for each mean difference fell within the 10% range (–2.8 to 2.8 for the hand, and –2.5 to 2.5 for the knee) and equivalence was assumed.
Conclusions. Adequately trained PEs can deliver clearly structured undergraduate skills, teaching with equivalent learning outcomes to those of rheumatology consultants. PEs are a valuable development to augment musculoskeletal education in the face of expanding student numbers.
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Introduction |
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Musculoskeletal disease is a common reason for primary care consultations and accounts for a large burden on healthcare [1, 2], but has been traditionally under-represented in undergraduate curricula [3, 4]. The teaching of musculoskeletal examination skills is commonly insufficient compared with other specialities. Unfortunately, this has led to a lack of confidence amongst clinicians regarding their musculoskeletal knowledge and examination skills [5, 6], as well as reported inadequacies in diagnosis and management of conditions in this field [7–10].
Traditional lecture-based teaching is of limited use when teaching examination skills, and small group skills teaching is widely accepted as the gold standard. However, increasing numbers of undergraduates and growing clinical commitments are placing a strain on existing teaching resources. Thus, to ensure the continuation of small group skills teaching we have to look to augment the numbers of trained teachers. Many units, including our own, have employed clinical educators (CEs) from allied health professions, such as nursing, physiotherapy and occupational therapy, to address this shortfall.
Trained patient educators (PEs) have also been used to teach various aspects of musculoskeletal history taking and joint examination. There are many potential benefits to using PEs. As a resource they can combine the roles of both teacher and patient. The role of teacher can be of benefit to the patient, including improved feelings of self-worth and positive temperament scores [11–13]. The use of PEs in addition to standard teaching increases both, the student self-reported skills levels and objective skills assessments when compared with those receiving standard teaching alone [14–17]. PEs are thus regarded as a valuable adjunct to clinical teaching. When compared directly with doctor-led teaching from doctors in non-musculoskeletal specialties, PE-led musculoskeletal teaching was found to be comparable in both student self-reported skills and improvement in knowledge [18]. An objective assessment of the skills of these students showed comparable, if not slightly superior outcome in the PE-led group, although this assessment was open to bias as it was not blinded [19]. To date, only two blinded, randomized controlled comparisons directly between rheumatology faculty-led teaching and PE-led teaching have been performed. The first recorded no difference in the performance in a single rheumatology objective structured clinical examination (OSCE) station in the end-of-year examinations between the two groups of students that had received 4 weeks of PE- or doctor-led musculoskeletal examination training earlier in the year [20]. The second study used a more rigorous nine-station OSCE at the end of the training and found that although the two groups did not differ statistically in their overall OSCE scores, the faculty-taught students had fewer failures [21]. One common feature of all these studies is the positive feedback attained by the PEs from the students.
If PEs were to be effective in augmenting teacher numbers, they would be required to deliver teaching in some instances instead of the rheumatology faculty. Any new method of delivering curriculum objectives needs to be evaluated to ensure that the level of educational outcomes is maintained. Therefore, we set up a study to directly compare the effectiveness, in terms of student learning outcomes, of PE-led teaching with that of doctor-led teaching using the methods detailed below.
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Methods |
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Patient educator recruitment
Having obtained ethical approval from the Southern Derbyshire Local Research Ethics Committee, we undertook recruitment between April and May 2004, at the Rheumatology Department of the Derbyshire Royal Infirmary. Six consultants, two nurse specialists and four nurses were asked to provide a list of patients they felt were appropriate to be approached to take part in this study. Patients needed to fulfil the following inclusion criteria: have good representative physical signs rheumatoid arthritis (RA) of the hands or knees, primary or secondary osteoarthritis (OA) of the knees; be fully mobile and able to cope with repeated joint examinations; possess good communication skills; have an aptitude for further learning and supportive teaching; be enthusiastic; have enough time to commit to the study; and be English speaking.
A total of 25 names were obtained, and many names appeared on more than one list. This strengthened the validity of the selection process, as more than one member of staff identified most of the patients. The patients were contacted and given written information about the study. Those who replied were interviewed to assess eligibility and obtain fully informed written consent. Twelve patients were recruited, which was twice the number required for the study to allow for withdrawals. Of the 12 patients, 11 were female and 1 male (mean age 51.4 yr, range = 34–79). The ratio of male to female volunteers reflects the make-up of the original list, and not a self-selection bias on the part of the patients. Ten had RA, one OA, and one inflammatory arthritis with secondary OA. Seven were retired, two were housewives, and three in current employment. Their employment backgrounds were: three teachers, three nurses, two housewives, one mining engineer, one bookshop owner, one self-employed businesswoman and one disability care worker.
Patient educator training
The PEs underwent 23 h of formal small group training for over 2 months between June and July 2004, with a similar amount of private study and one-to-one teaching. The course took place at the Derbyshire Royal Infirmary over a series of half days with evaluation and feedback, to enable them to deliver a structured small group teaching session based on established core hand or knee examination skills [22]. The training course was delivered by N.R.
The training course and accompanying manual was written and devised by N.R. based on an expert consensus opinion of six consultant rheumatologists and one specialist nurse. It was felt by the consensus group that the PEs should be taught the following:
- Why musculoskeletal disease, and hence joint examination is important (to enable the patients to put the skill ‘in context’ for the students).
- Basic anatomy descriptor terms, including synovial joint components.
- Terms relating to the movement or position of a joint or limb.
- A basic glossary of terms used in rheumatology.
- The general principles of joint examination.
- Phonetic pronunciations of all relevant terms.
- Related anatomy and deformities.
- The core hand and knee examination skills.
- Principles of how to teach to adult learners.
The manual was designed based on a standard rheumatology examination text having obtained permission from the author [23], and was then successfully piloted for readability with rheumatology patients and laypersons of varying ages and reading abilities. The average reading age of the manual was calculated using the 4F method as 15.85 yrs [24].
The patients were paid a small honorarium for the amount of time taken to train and teach (£10 per half day, £20 per full day, plus travel expenses); similar to a recent UK-based PE scheme [17]. The majority donated these funds to charity.
Student recruitment
Final year medical students (n = 50) from Nottingham Medical School were recruited to take part in this study. Those with no prior formal musculoskeletal examination training were recruited, and written consent was obtained for them to be randomized for doctor or patient-led teaching followed by a two-station OSCE.
Student teaching and assessment
The students were block-randomized to receive two 60 min structured small group teaching sessions in the hand and knee examination. Group A were taught hand examination by a PE with RA, and knee examination by two PEs with OA (one acting as teacher, and the other as the model). Group B was taught hand and knee examination by a consultant rheumatologist (either S.C.O'R. or C.M.D.) plus an untrained patient with appropriate signs. All students were taught in small group skills workshops using established core skills. Four days later, the students undertook two validated OSCE stations [25] with two blinded assessors (N.R. and L.J.B.) whose scores were averaged for each student. The 4-day delay was to eliminate any student ‘immediate recall’ bias upon testing. The students were not timetabled, or permitted, to have any additional hand or knee examination training in this 4-day period. This was ensured by the cooperation of their clinical teachers during the study. Validated pre- and post-teaching questionnaires established the students’ self-reported levels of skills (SRS) [19]. A student evaluation of teaching (SET) questionnaire using a five-point Likert scale was also administered after each teaching session.
Evaluation of the PE scheme
Both PEs and students were interviewed after the study to obtain feedback about the scheme and explore their views. These took the form of semi-structured interviews that were recorded on audiotape and then transcribed in full. The same process was also applied to an additional focus group of medical students. The interview and focus group data were coded using the constant comparative method, comprising open, axial and selective coding, consistent with a grounded theory approach [26]. Triangulation of the interview, questionnaire and feedback session data increased the validity by demonstrating that the same conclusions could be drawn when different strategies are used to observe the same phenomena [27].
Statistics
The study was analysed as an equivalence trial. A mean difference in OSCE scores of 10% was assumed to be of educational significance. A pilot of the OSCE stations was performed using third year medical students (n = 21) who had undergone the same teaching sessions as in the main study prior to testing. The spread of their scores for both the hand and knee stations were normally distributed. The group mean score and variance data from this pilot study [25], were used to establish that for 80% power the total numbers of students required were 42 for the hand and 24 for the knee OSCE. This was based on the assumption that the third year students would have a similar mean and variance to that of the fifth year students, which was eventually shown to be the case.
All data were tested for normality using Kolmogorov–Smirnov analysis and means were compared using an independent sample t-test. (SPSS v13).
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Results |
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Patient educator training
Eleven PEs completed training (seven for the hand and four for the knee examination), and six went on to teach. One PE withdrew before the training started due to unavailability on the majority of the planned training days. This patient stated that they were willing to take part in similar training if the course was ever run again. Ten PEs attended a further group session lasting 1 h, and individual 1:1 top-up teaching was undertaken for four PEs at their request, totalling 4 h. For quality assurance purposes, we estimate that this scheme will require between 4–6 h of top-up teaching per year, a figure that would decrease as the experience of the PEs increase.
The total cost of the scheme that included honoraria, travel costs, catering, room hire and teaching materials came to £800. The future running costs would be lower, at about £5 per hour of PE teaching, plus travel expenses. Once established, this represents a cost-effective delivery of small group teaching when compared with consultant-led teaching. Feedback from the PEs on the training course was positive and their comments have been used to inform slight changes to the manual and the sessions for future use.
Student teaching and assessment
The students were randomized into two equal groups (n = 25). Apart from SET scores, which were still high in both groups, the two student groups did not differ significantly (Table 1). There were no significant differences in mean hand OSCE (mean difference = 0.88, P = 0.28, 95% CI = –0.73 to 2.49) or knee OSCE (mean difference = 0.28, P = 0.7, 95% CI = –1.19 to 1.75) scores. Both the upper and lower confidence intervals for each mean difference fell within the 10% range (–2.8 to 2.8 for the hand and –2.5 to 2.5 for the knee) and equivalence was assumed.
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The students’ hand and knee OSCE results correlated moderately with their eventual overall OSCE score from their final examinations (hand: R = 0.44, P < 0.01, knee: R = 0.46, P < 0.01). This moderate correlation with other indices of clinical skills is in keeping with the levels of internal correlates of the final examinations [28].
The SET scores for both the PE and consultant-led teaching were high for both the hand and knee examination. There was a significant difference in the overall scores but a detailed breakdown of the median scores for each group showed that the PEs achieved an acceptable level of feedback in most facets of their teaching (Table 2). It is not surprising that the consultant group scored higher in these evaluations due to their relative expertise and familiarity with the subject matter.
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Evaluation of the PE scheme
The PEs enjoyed the training and those who went on to teach found the experience less daunting than they had first envisaged. Indeed, they had expressed initial apprehension about teaching medical students, answering any questions, and that the students may not view their teaching favourably. They had been worried about not having a member of the faculty available to help with questions but this decreased after they were prepared with answers to common questions. Those who taught described a feeling of self-worth and confidence and being able to finally use their illness in a positive manner. Many would have liked to teach more often to allow them to maintain and improve their teaching skills. The issue of expenses and the honorarium differed depending on whether the patient was still in employment. Interestingly, those in employment would value an increased payment to compensate for their time, whereas those on benefits would prefer the current honorarium or donating it to charity, as an increase would affect their benefits. Both groups agreed that they did not take part for financial reasons. The overwhelming reasons for enrolling were either to give something back to the health service, or to be involved in something meaningful. The patients felt that the students benefited from seeing how arthritis affects the individual and that the students concurred with this.
The students gave a good feedback about the PE teaching, although not as good as that given for consultant-led teaching. The students felt that this level of performance was adequate for their learning needs and that the PEs would improve with time. Many of the areas identified for improvement were related to the experience of the teacher, such as the timing of the session and the provision of constructive feedback. The students felt that the skills were put into context well by the PEs and were surprised at the level of technical knowledge. They found the sessions to be relaxed and non-judgemental and reported to have enjoyed learning in this setting. They felt that as long as they would have subsequent access to faculty at later stages of their training to learn about the musculoskeletal disease management, it was reasonable to be taught clinical skills by PEs alone.
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Discussion |
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Main findings
This randomized trial directly compared rheumatology consultant teaching with that of PEs using a blinded objective assessment and showed equivalence in specific teaching outcomes. Our educational aim was the effective delivery of core hand and knee examination skills to the students. These skills were then objectively measured in our two student groups using two validated and reliable OSCE stations designed for this purpose [25]. Much of the previous work in rheumatology PEs has focused on the addition of PE teaching to a curriculum, and compared those students who underwent the standard teaching with those who had standard teaching plus the PE intervention [14–17]. These studies all showed additional benefit in terms of either student self-reported skills or objective skills assessments. From this we can conclude that this additional teaching was effective and that the use of PEs in this augmented role is of educational benefit.
However, in order to consider the use of PEs to take on some teaching sessions instead of the doctors we must directly compare the teaching outcomes of these two groups to ensure that adequate standards of education are met. Prior to this work, two blinded, randomized controlled studies had addressed this issue. The first recorded no difference in the performance in a single rheumatology OSCE station in the end-of-year examinations between the two groups of students that had received 4 weeks of PE or doctor-led musculoskeletal examination training earlier in the year [20]. The time delay between teaching and testing has the potential to bring in confounders such as teaching contamination, as students may have received further joint examination training before the finals. Another potential problem was that only one testing station was used, thus allowing only a single regional examination to be tested out of the many that were taught. The second study used a more rigorous nine-station OSCE at the end of the training and found that although the two groups did not differ statistically in their overall OSCE scores, the faculty-taught students had fewer failures [21]. Our study has shown similar equivalence in OSCE scores between the PE and doctor-taught groups. Testing our students soon after teaching and recording their self-reported skills and knowledge scores reduced the potential for any teaching contamination.
The students’ own evaluation of the teaching showed that both the consultants and the PEs scored highly, although there was a statistically significant difference in favour of the consultants. This finding was to be expected. The PEs were teaching students for the first time and some of the individual facets of the feedback reflected this, such as the overall timekeeping of the teaching session. The consultants had been teaching these skills in this format for many years and were familiar with the subject matter and their feedback scores reflected this. At the interview, the students agreed that the PE teaching was of an acceptable standard for their learning needs and that with more experience the PEs would only ever get better. The students also described the PE-run sessions as relaxed, non-judgemental and a ‘safe’ teaching environment run by enthusiastic teachers. These findings are echoed in other works on PEs [17, 18, 20]. Indeed, in addition to clinical competence, the qualities that faculty and students hold in highest regard for an effective clinical teacher have not changed over the last 40 yrs [29, 30]. Good teachers are enthusiastic, approachable, non-judgemental and stimulating.
OSCEs are regarded as a valid and reliable method of objectively assessing skills [31–33]. We used an OSCE as we sought to objectively measure the impact of PEs on the performance of the hand and knee examination as a precise outcome measure of their teaching, but realize that the PEs may possibly also influence student attitudes and communication skills. Interview and focus group data collected from the students suggest that the PEs did provide them with insights into coping with arthritis, and had a positive benefit on their communication skills training.
The feedback from both the PEs and the students was positive. The PEs reported personal benefits in keeping with other PE schemes [11–13]. The issue of not having a faculty member present during teaching was not felt to be detrimental to the actual core skills session, but both PEs and students felt that it would be essential to have access to faculty as part of the course. The faculty were kept out of these sessions to allow us to explore the effectiveness of PE teaching without any contamination. However, in practice, one faculty member could oversee many concurrent skills sessions run by PEs and address any problems that arose, and this would be one model for coping with increased student numbers. A key feature of these skills workshops is that the learning objectives are clearly defined. This allows the PE to operate within their own range of competency, and informs the learners of what precisely to expect from that session.
Limitations
In an effort to minimize contamination from other teaching sources, we recruited the students before they had undergone their musculoskeletal medicine module in the final year. This makes the assumption that they had not been exposed to any formal teaching concerning hand or knee examination. Although it is unlikely that all the students would be completely unfamiliar with all aspects of the examination of these joints, we endeavoured to minimize the effect of any previous knowledge using the randomization process and recording their pre- and post-teaching self-reported skills scores. There were no significant differences between the two groups in their scores before or after teaching, but there was a similar increase in knowledge reported as a result of the teaching intervention.
This study was adequately powered as an equivalence study. However, such studies can never categorically prove or disprove equivalence. The nature of our results makes us reasonably certain that the two interventions were equivalent, but it must be noted that the basis of this assumption is derived from pilot data [25] and expert consensus opinion that a 10% difference in the means of the two student groups would be of educational significance.
Implications
This study has shown that properly trained PEs can deliver clearly structured undergraduate skills teaching with equivalent learning outcomes to those of rheumatology consultants. PEs are a valuable development to augment musculoskeletal education in the face of expanding student numbers. We have found the use of PEs to be an effective way of increasing clinical teacher numbers, but this project is intensive in terms of clinician's time to set-up and train the PEs. To improve on the return from this effort we envisage the PEs taking part in OSCE style feedback session for the students. This kind of formative assessment has been well received by students as it gives them an idea of how their skills are progressing, despite not being a high stakes examination. The scope of the PEs could also be widened to include other regional examination, discussion about the effects of disease on their daily lives and history-taking skills. Regardless of how the PEs are employed, and despite the positive impact that this involvement in teaching has on the patients, it is essential not to take their hard work and good will for granted. Issues such as expenses, teaching honoraria, indemnity and honorary teaching contracts need to be addressed if their roles expand into a more formal teaching capacity.
The authors have declared no conflicts of interest.
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