This appropriately powered study demonstrates that there are no significant differences in MSK physical examination OSCE scores or interpersonal skills OSCE scores between students taught by trained patient educators and those taught by usual non-MSK specialist physician tutors. This study adds to the current patient educator literature in that it provides rigorous evidence for a much more practical approach to integrating arthritis patient educators using the currently employed standardized PP®
IA program. It evaluates the effectiveness of a much more realistic and generalize-able intervention, that being a brief patient educator teaching session, and uses a much more realistic and generalize-able comparator, that being non-MSK specialist physician tutors than has been reported in previous literature. This real-life intervention is supported by recent surveys of actual practices in MSK clinical skills teaching in Canada [56
This brief teaching session was also successful in improving students' retrospective pre and post ratings of comfort levels with many different aspects of MSK examination. It is reassuring that both groups' perceptions of comfort improved after the teaching and tOSCE sessions. It is also interesting that where significant differences did exist between the groups, PP®IA patient educator led students consistently reported more improvement in their comfort levels than did physician tutor led students. With such a short teaching intervention, it is probably not surprising that significant differences in stated interest in further study in MSK were not seen.
One of the two rigorously conducted previous studies also showed PP®
IA patient educator teaching can result in similar OSCE scores for a nine hour teaching intervention compared to a similar duration session given by rheumatologists [52
]. However, this study cannot comment on actual equivalence, as power calculations were not presented. Previously published surveys show that this amount of either patient educator led small group time or specialist-led small group time far exceeds what the vast majority of schools currently provide [3
]. The current study's findings extend the results of Humphrey-Murto's study to a shorter teaching intervention of two hours total duration, which is more realistic in the preclinical setting. This study also extends these findings from MSK specialist physician tutors to general physician tutors. This is very relevant as survey data documents that non-MSK specialist clinical teachers teach MSK clinical skills at 60% of Canadian medical schools [56
Although the other rigorously conducted study did present power calculations and did find equivalence between patient educators for a 2 hours intervention, it also used rheumatologists as its comparison, which again is not representative usual teachers of MSK clinical skills in most universities. In addition, this study did not use the existing standardized patient educator training program (PP®
IA), but rather employed its own unique training strategy to prepare patient educators which further limits the ability to generalize findings to other centres [55
Unlike the Humphrey-Murto study, there were no tOSCE stations showing significant differences between the patient educators and physician tutor groups in the current study. One potential consideration that may account for this is the fact that the two stations where they found significant differences (ankle examination and sciatica examination) were not included in our tOSCE. The objectives for our teaching sessions were clear in their inclusion only of major peripheral joints. When considering the short time available, the authors did not feel that both the spine examination and the complete peripheral joint examination could be meaningfully covered in a two hour teaching session. However, the differences that they found were both in favour of the rheumatologist taught students. In our study, the hip station was the only one that came even close to significance and unlike the previous study, this was in favour of the patient educator taught students. It must be noted, however, that the current study focuses on peripheral joint exam and these finding may not be extrapolated to other aspects of MSK examination such as spine, soft tissue, power or gait examinations.
There were only five tOSCE stations used in our study compared to nine stations in Humphrey-Murto's study. When determining the numbers of stations to include in our tOSCE, it was important to consider teaching "dose" versus examination duration. Since only two hours of teaching were provided in this study, it was difficult to justify a nine station tOSCE. In attempts to resolve this dilemma, the author consulted two international experts in clinical skills evaluation (CV and LG). On considering their advice, it was decided that a five station OSCE would give the best balance of reliability through number of stations and sampling validity through an appropriate teaching to examination ratio.
There are several limitations that need to be considered when interpreting the results of this study. They include potential issues relating to sampling validity, sensitivity of the outcome measures and external validity.
Firstly, one must consider how representative the sample studied is compared to the general cohort of both instructors and students. As part of the criteria for the study, none of the physician tutors were specialists in MSK disciplines such as rheumatology, orthopedic surgery or physiatry. In all cases, the tutor agreed to give this MSK session. This reduced the possibility that participating tutors were more or less skilled at teaching MSK PE as all were included. Some of the participating tutors did express that they had not taught MSK PE when they taught this course in the past. This would indicate that we were not dealing with a group of general physician tutors that were unusually confident in their MSK teaching. The patient educators who participated in the teaching volunteered to give three two-hour teaching sessions over the 21 week IIM course. Although it could be argued that those who volunteered may have been more committed to the program, this type of selection would be parallel to what would occur if patient educators were asked to participate in actual undergraduate teaching sessions of similar duration. In terms of the students, student assignment to hospital site was quasi-random through the central Undergraduate Education Office and the few requests for change in placement occurred prior to students' knowledge of the study. Thus, it is unlikely that these requests would have caused systematic differences between these students and those at the other teaching hospitals.
Another potential question to the validity of the study relates to whether the tOSCE tested material that was representative of what students should learn in an undergraduate MSK PE session. The OSCE was structured around course objectives that were derived from the literature review on undergraduate MSK teaching objectives. One may wonder if a tOSCE is sensitive enough to pick up relevant differences between the intervention groups. However, a similar OSCE did pick up differences in the previous study by Humphrey-Murto and the reliability of 0.67 for the current study's OSCE was similar and high according to Cohen's guidelines [66
]. One may also question whether the seven to ten day delay between the teaching and the tOSCE was appropriate. We chose this timing to minimize the influence of confounders on the results but we recognize that future studies with a second delayed OSCE to evaluate long-term retention would be desirable.
One may also wonder if the novelty of this intervention created a Hawthorne effect. However, as there was a change to the normal structure of both groups by way of the presence of a community arthritis patient or a patient educator, and as no differences were found between the groups this is unlikely to have had a major confounding effect. Had it done so, one would expect that the patient educator group would have outperformed the physician led group and this was not the case. One may also question the validity of student self-assessment. However, this study does not draw conclusions on the absolute self-confidence ratings but rather evaluates the comparison between two quasi-randomly selected groups of students. There is not reason to believe that there would be differences in the reliability of this data between the two groups.
Finally one may question whether the findings from a study performed at one University in one country can be generalized more widely. Fortunately, when comparing this university's practice to those reported in national Canadian, American and UK surveys, the amount of teaching offered appears more in line with standard MSK teaching practice in that a very brief amount of MSK clinical skills teaching is offered, it is offered primarily by non-MSK specialist physicians and is supplemented by patient educators [3
There are many interesting points raised by this study. For example, the authors find it somewhat unusual that there were no differences in physical examination skills tOSCE scores despite reports from the qualitative data referred to earlier in this paper that some physician tutors did not manage to cover all of the specified joints in their teaching sessions [63
]. These findings may be explained by the fact that students were aware of the upcoming OSCE and may have read independently to bring their knowledge in par with objectives regardless of teaching content or source. Although assessment is known to drive learning, previous studies with non-teaching comparison arms have demonstrated significant differences in MSK PE skills even when students were aware of an upcoming tOSCE [37
In a qualitative analysis that occurred in parallel to this study, the authors found that physician tutors were more likely to emphasize the verbalization of physical exam manoeuvres as they were performed, than patient educators [63
]. Differences in the students' abilities to express rather than perform skills could have led to a bias in the results in favour of the physician tutor group. Despite this, no significant differences were found.
The early introduction of patients into the undergraduate medical curriculum is desirable as it may improve the authenticity of the teaching experience by making the context of the learning environment similar to what students will experience in their future clinical roles. Patient educators give students experience on how to conduct themselves in front of real patients and give them more responsibility to develop rapport with patients who can give specific feedback in the absence of supervising physicians. Furthermore, patient educators provide students with explicit opportunities to learn from patients, appreciate patients as knowledgeable partners, and incorporate the patient's perspective as part of the educational messages.
The development of strong MSK PE skills is important for accurate diagnosis of common MSK complaints in both primary and specialty based patient care. As discussed in the introduction, MSK conditions comprise a significant proportion of current health care visits and this is likely to be more important in the future with the aging of the population. The initial reluctance of the physician tutors to include an MSK PE session in their usual teaching in this undergraduate clinical skills course underscores the fact that this teaching was likely not consistently occurring prior to this study.