SEARCH

SEARCH BY CITATION

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information

Medical Education 2010: 44: 347–357

Objectives  There are recognised difficulties in teaching and assessing intimate examination skills that relate to the sensitive nature of the various examinations and the anxiety faced by novice learners. This systematic review provides a summary of the evidence for the involvement of real patients (RPs) and simulated patients (SPs) in the training of health care professionals in intimate examination skills.

Methods  For the review, ‘intimate examinations’ included pelvic, breast, testicular and rectal examinations. Major databases were searched from the start of the database to December 2008. The synthesis of findings is integrated by narrative structured to address the main research questions, which sought to establish: the objectives of programmes involving RPs and SPs as teachers of intimate examination skills; reasons why SPs have been involved in this training; the evidence for the effectiveness of such training programmes; the evidence for measures of anxiety in students learning how to perform intimate examinations; how well issues of sexuality are addressed in the literature; any reported negative effects of involvement in teaching on the patients, and suggestions for practical strategies for involving patients in the teaching of intimate examination skills.

Results  A total of 65 articles were included in the review. Involving patients in teaching intimate examination skills offers advantages over traditional methods of teaching. Objective evidence for the effectiveness of this method is demonstrated through improved clinical performance, reduced anxiety and positive evaluation of programmes. Practical strategies for implementing such programmes are also reported.

Conclusions  There is evidence of a short-term positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still limited. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information

There are recognised difficulties in the teaching and assessing of intimate examination skills.1,2 These difficulties reflect several factors, including: the sensitive nature of the various examinations and potential embarrassment to patients;3,4 anxiety and discomfort related to sexuality amongst novice practitioners;5 fewer practice opportunities in clinical settings because of time constraints;6 difficulties in finding patients who are willing to be examined by students,3,7 and the known limitations of traditional methods of teaching these skills using manikins, anaesthetised patients and videos.8 Patients have always played an integral part in undergraduate and postgraduate medical education, previously as passive, clinical exemplars and more recently as active facilitators in the development of clinical skills.9,10 The active involvement of patients, both real and simulated, in training students and doctors in intimate examination skills has been reported extensively. However, the educational impact of this involvement has not been systematically studied.

The aim of this review is to integrate the evidence on the role of patient involvement in the teaching and assessing of intimate examination skills of health care professionals.

The data elicited from the review will be synthesised to address the following research questions.

  • • 
    What are the objectives of programmes involving real patients (RPs) and simulated patients (SPs) as teachers of intimate examination skills?
  • • 
    Why have SPs been involved in intimate examination skills training?
  • • 
    What is the evidence for the effectiveness of the training programmes?
  • • 
    Are there any measures of anxiety in students learning how to perform intimate examinations?
  • • 
    How are issues of sexuality addressed in the literature?
  • • 
    Is there any evidence for a negative impact of patient involvement in teaching?
  • • 
    What are the practical strategies for involving patients in the teaching of intimate examination skills?

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information

Design

We carried out a cross-sectional survey of primary empirical research on the teaching and assessment of intimate examination skills for health care professionals, employing a systematic review method. A review protocol was written using standard guidelines.11,12 In this review, intimate examinations included pelvic, rectal, breast and testicular examinations; patients included RPs in clinical settings as well as SPs.

Search strategy

We searched MEDLINE, EMBASE, Educational Resources Information Centre (ERIC), PsychINFO, Sociological Abstracts, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Topics in Medical Education (TIMELIT) from the start of each database to December 2008 (Appendix S1). We also hand-searched three key medical education journals (Academic Medicine, Medical Education, Medical Teacher) and scrutinised reference lists of articles already identified as meeting the review inclusion criteria for additional studies.

Inclusion criteria

Articles published in English reporting primary empirical research on the teaching or assessment of intimate examination skills in health care professionals were included initially. Studies were excluded if they employed a review or case methodology or described interventions without evidence of evaluation.

Data extraction and validity assessment

Study inclusion, quality assessment and data extraction were conducted by four authors (VJ, ZS, AA-H, NDQ) and differences were resolved by discussion. The data extraction form was developed from the literature.11,12 As most of the studies in this area employ a cross-sectional, before-and-after or cohort study design, the traditional hierarchy of evidence quality assessment would not be sensitive enough to discriminate the scientific rigour of the empirical research identified by this review. A set of criteria for assessing the quality of the studies was developed using guidelines12 and included: the theoretical construct of the study; the clarity of its aims; the clarity of methodology, and the definition and measure of outcome.

Data synthesis

Frequency tables are used to summarise the studies’ characteristics. The details of teaching and assessment methods are summarised. Statistical integration of data was not possible as there was no consistency in the areas of education involving patients, the designs employed or the measures of effectiveness assessed. The synthesis of findings is integrated by narrative structured in a way to address the objectives of the review.13

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information

Summary of study characteristics

Number of studies

The search identified 7071 abstracts; 363 articles were selected for further review. The final review included 65 articles. The majority of articles (48) were identified from electronic databases and the balance (17) were identified from reference lists. Articles were most likely to have been published in Academic Medicine or its predecessor, the Journal of Medical Education (Table S1).

Source of studies

The majority of studies (55) were carried out in the USA. Three originated from each of Sweden and Canada, two from the UK and one from each of Austria and Belgium.

Samples

The majority of articles described interventions amongst undergraduate medical students.3,5–8,14–55 The remainder described outcomes amongst postgraduate trainees,56–63 practising clinicians,64–69 other health professionals70 and other groups71–73 (Table 1).

Table 1.   Samples and aims of articles
 DescriptionTotal number of articles and reference number(s)
SamplesUndergraduate medical students483,5–8,14–55
Postgraduate medical students856–63
Practising clinicians664–69
Others170 used other health professionals; 271,72 used mixed samples; 173 had no student samples but described patient feedback on being involved in teaching
Aim of studyEvaluation of student/learner outcomes as a result of an intervention353,5–7,14,16–18,20,26,28–30,32,35,37,39,42,43,46,47,50,51,53,55–57,60–62,65,66,69,71,72
Development and evaluation of educational programmes228,15,19,21–25,27,31,33,34,36,40,44,45,48,52,54,58,59,67
Assessment of skills538,49,63,64,68
Experiences of students/patients following teaching341,70,73
Aims of studies

The main aim of the studies was to report the evaluation of student or learner outcomes that resulted from an intervention (Table 1).

Type of examination and method of teaching or assessment

Most articles referred to only one type of examination Twenty-nine articles referred to pelvic examination, 17 referred to breast examination and two referred to rectal examination (Table S2). Nine articles described pelvic and breast examination; two included rectal and testicular examination, and three included all four types of examination. In addition, one article described pelvic, testicular and rectal examination, one described pelvic, rectal and breast examination, and one described pelvic, testicular and breast examination.

Of the 65 studies, 16 used RPs either exclusively (n = 5) or in combination with SPs and the remaining 49 used SPs only. Most articles reported an active role for SPs as teachers or assessors; however, only two6,62 allowed RPs to actively evaluate the performance of the learners.

Design of studies

A variety of study designs were employed. The majority of studies (n = 33) described the development and evaluation of training programmes; the other designs employed included quantitative methods (n = 16), randomised trials (n = 5), pre-post design (n = 7), both qualitative and quantitative methods (n = 2), qualitative methods (n = 1) and comparative methods (n = 1).

Quality scores for study rigour

Each study was objectively rated for scientific rigour. This was carried out independently by four of the authors (VJ, ZS, AA-H, NDQ). All four authors agreed on the quality scores for 80% of the articles. The remaining 20% of articles were discussed between the four authors until agreement on their quality scores was reached. All studies rated well on reporting a clear aim and a clear description of the methods; most rated well on having a well-defined outcome (except n = 5) and an appropriate measure of outcome (except n = 8). Only six articles reported an explicit theoretical underpinning to inform their interventions; these were drawn from psychology,47,66 education,32,65,70 ethics22 and sociology.15

Integration of findings by narrative

A more in-depth, narrative integration of findings13 was carried out on all the articles. Findings were synthesised to answer the following research questions.

What are the objectives of programmes involving RPs and SPs as teachers of intimate examination skills?

Teaching and assessing clinical competence

Clinical competence represents a combination of technical skills and effective communication with the patient. The majority of articles (n = 47) described programmes to develop or assess intimate examination clinical skills.3,5–8,15,16,20,22–24,26–30,32–37,40,42–46,48–51,54–58,60–62,64–68,70,71 Of these, 18 articles3,8,15,20,22,23,27,29,30,33,34,42,48,50,58,61,65,72 focused on the communication and interpersonal skills required during intimate examinations. Good examples of studies using both objectives included:

  •  programmes that specifically focused on the development of the doctor–patient relationship during physical examination instruction, including the use of explanation and reassurance, communication of information during examination and the promotion of patient autonomy;15
  •  a specific measure of doctor counselling skills during breast examination using a checklist to evaluate three dimensions of counselling: stage of readiness and related barriers; identification and counselling of patient barriers, and communication skills,65 and
  •  an innovative student-selected component (SSC) in which students reflected on their communication and technical skills and evaluated their ethical concerns regarding examination.22
Reducing anxiety for students and patients

This was the main objective in the programmes described in seven articles.5,17,27,34,51,53,62 The issue focused on the objectives listed below.

  •  One paper focused on reducing initial student anxiety during the first attempt at pelvic examination by emphasising the alleviation of anxiety and patient reassurance.27 The Pelvic Examination Educational Programme17 and the programme described in another study34 aimed to reduce anxiety and patient discomfort by training students to achieve confidence in pelvic examination techniques. Reducing anxiety during pelvic examination in a very specific group (adolescents) was the focus of a programme for paediatric residents.62
  •  Obtaining objective measures of student anxiety before, during and after pelvic examination was the main objective in two studies.5,51 This is discussed in detail below.
  •  Changing the attitudes of students towards the pelvic examination and female sexuality through training by gynaecology teaching associates (GTAs) was described in one study,53 in which students completed a questionnaire on female reproductive anatomy, physiology and emotions before and after the teaching.
Increasing awareness amongst students

This included awareness regarding concerns that patients may have15,33,44,58 or ethical awareness of issues pertaining to intimate examination training.22,36

  •  One study highlighted an opportunity for patients to express their anxiety or concerns during breast examination.44
  • • 
    One programme focused on issues such as the use of drapes or stirrups and previous experiences of pelvic examinations.15
  • • 
    One SSC encouraged the adoption of an ethical thinking approach during intimate examination.22
Implementation into postgraduate training

Three articles focused on extending the use of SPs into postgraduate training.56,59,61 The objectives included reinforcing undergraduate teaching using GTAs in postgraduate teaching56,59 and exploring the benefits of such teaching in postgraduates.61

Why have SPs been involved in intimate examination skills training?

Most studies employed SPs because of the previously reported acceptability of this method. Specifically, SPs have several advantages over traditional methods of instruction.

  •  The use of SPs addressed some of the drawbacks of learning from RPs in clinical settings. This included students’ feelings of inhibition in front of RPs60 and their finding it stressful22,33 or threatening18 to practise on them. There were also practical issues involved in finding willing patients in clinics8,28,38 and ethical issues related to using RPs to teach,8,27,40,44,45 including the infringement of patients’ rights. In addition, RPs do not provide feedback to students on their clinical performance, whereas SPs are specifically trained to do so in a structured manner, both during and after the examination.3,6,7,33,50,54,61,68,70
  •  The use of manikins to teach intimate examination skills is disadvantageous in that the method lacks realism,21 manikins are unable to provide feedback, and training on manikins is limited to technical skills and does not emphasise interpersonal skills development.
  •  Using anaesthetised patients involves practical issues including the obtaining of informed consent,19 the lack of feedback from patients and the focus on technical skills only. Furthermore, using anaesthetised patients does not duplicate the conditions in which most intimate examinations are carried out.19

Moreover, encouraging patients and members of the public to participate in health education was seen as a means of empowering patients to achieve enhanced health information.15

What is the evidence for the effectiveness of the training programmes?

A summary of programmes demonstrating objective evidence of effectiveness is presented in Table S3. The effectiveness of involving patients in intimate examination skills teaching and assessment was measured in the following ways.

Improved clinical performance

Some studies showed improvement in learners’ clinical skills performance as a result of training by patients. This improvement was measured through objective structured clinical examination (OSCE) scores,14,16,28,46,55 assessment by teaching associates (such as GTAs),18,56 skills assessment after teaching,20,24–26,29,37,50,62,65,68,69 self-assessment,6,7,57,61,62 and increased ability to palpate anatomical structures (ovary, breast) or pathology (breast lumps).35,39,43,60,71 One study32 reported improved clinical performance after mental exercise to recall the steps of gynaecological examination. Two studies reported an increased number of pelvic examinations37 or pap smears44 performed in clinical practice following instruction by SPs, although it is difficult to attribute this directly to the training session.

Positive evaluation of the teaching programme

Positive evaluations were reported from learners,3,6,15,18,21,22,24,27,28,31–34,36,40,44–46,48,51,52,54,58,59,62,67,69,70 patients17,41,45,52,62,73 and faculty staff.25 The learners found teaching using SPs to be useful in that it enhanced understanding of the doctor–patient relationship,15,34,51 provided immediate and constructive feedback on performance,15,27,28,31,36,58 was less threatening than examining RPs in clinics22,27,28,34,51,73 and facilitated a better understanding of the examination process.44,70

One study provided a summary of patients’ views on their gains from participating in the teaching.73 The authors identified five themes from their interviews with GTAs, which included embodied knowledge (of their own bodies), promoting a proper approach (to intimate examination), redrawing private boundaries (and active partnership with learners), feeling confident, and doing something meaningful.

Faculty evaluation of teaching programmes was reported as positive.25 Faculty members felt that students came to clinics better prepared in technical and communication skills following training by GTAs. There were also reports of savings in terms of instructor and faculty staff time by training patients to provide the major teaching of pelvic examination skills.39

Improved knowledge of intimate examination

One study reported that students who were trained by a rectal training associate (RTA) scored significantly higher on knowledge testing than those who did not receive instruction by RTAs.28 Another reported a significantly improved ability to take pertinent history for students taught breast examination by SPs.50

Reduced anxiety in learners

Reduced anxiety was reported either in the form of perceived reduced anxiety by students8,39,44,51,53,70 or through objective measures of anxiety using the State Trait Anxiety Inventory (STAI)18 or heart rates.5 One study reported a greater reduction in anxiety following instruction by SPs than after instruction by RPs, but the difference was not statistically significant.18 Significant variations in anxiety levels at different stages of the pelvic examination were reported, with the highest rates occurring during bimanual and recto-vaginal examinations.5

Improved communication skills

Various studies reported improvements in skills related to communication, including counselling skills,8,65 professionalism,29 awareness of patient comfort7 and interpersonal skills.8,51,72

Are there any measures of anxiety in students learning how to perform intimate examinations?

Some explicit measures of anxiety are reported in the literature.

  • • 
    The STAI was used in two studies5,18 prior to or following teaching by SPs. This is a questionnaire with high reported reliability that measures anxiety both as a personality trait (proneness to be anxious) and as a state of anxiety (how anxious the individual is at a given moment).
  • • 
    A self-perceived anxiety inventory containing selected items from the STAI was created by the authors of one study.5 This was a graphic instrument that contained descriptors for the rating scale. The scale was placed on the vertical axis and ranged from 1 (felt at ease, calm, relaxed) to 5 (felt anxious, tense, worried). The horizontal axis contained each portion of the pelvic examination and included points for before and after the examination.
  • • 
    One study described anxiety graphs and electrocardiography to record changes in heart rates during instruction and examination.5 Mean heart rates for each segment of the examination were measured to assess levels of anxiety.
  • • 
    The Gynaecologic Examination Distress Questionnaire (GyExDQ) was used to rate feelings of distress and global fear amongst students.6 Students rated their feelings at the prospect of performing the eight consecutive steps of the pelvic examination. For each step, students rated global fear, impulse to avoid the situation, disturbing thoughts or associations, discomfort and stress on a scale of 0–6 (0 = not at all, 6 = extremely strong/intense). In the GyExDQ, scores for all eight steps were summed up to indicate the degree of distress the student felt about performing a pelvic examination.
  • • 
    Questionnaires on self-reported anxiety levels8,39,51,70 provided some measure of anxiety before or after examination of simulated or professional patients.
  • • 
    Some studies referred to a measure of anxiety regarding examination as part of the programme evaluation process.7,40,44

How are issues of sexuality addressed in the literature?

Only eight articles explicitly addressed this area:

  • • 
    one training programme addressed assumptions about the patient’s sexual orientation and demonstrated that avoiding these assumptions could reduce anxiety during pelvic examination;15
  • • 
    one article reported explicit discussion by professional patients about the myths of sexual arousal and the sexual vulnerability of women during pelvic examination;7
  • • 
    one paper reported differences in the approach to intimate examination between genders and showed that male students were more likely to be jocular and less serious during the examination of both male and female patients;52
  • • 
    one paper reported that anxiety regarding sexual arousal and disturbing thoughts was significantly lower after teaching by professional patients compared with before instruction;6
  • • 
    two articles described developing awareness of sexuality issues through videos prior to examining patients,36,47 and
  • • 
    two articles respectively explored the sexual attitudes of GTAs, who reported a lack of sexually charged atmosphere during training, and students, who were asked to reflect on their attitudes towards using sexually suggestive terminology during examinations.37,43

Is there any evidence for a negative impact of patient involvement in teaching?

Few articles reported a negative impact of patient involvement in teaching intimate examination skills. The negative impact was measurable by:

  •  no improvement in clinical performance with regard to either technical performance scores5,42,51 or changes in distress on examination;6
  •  negative evaluation of the teaching programme because students found it distasteful to examine healthy volunteers and could not ask clinical questions15 and some students felt less anxious whilst practising on manikins;69
  •  negative evaluation of the teaching programme arising from practical issues such as difficulties in scheduling sessions,27 and
  •  reports from GTAs of relationship problems and an increased risk of vaginal infections41 and reports from teaching associate simulated patients (TASPs) of discomfort during genital and rectal examination.33

What are the practical strategies for involving patients in the teaching of intimate examination skills?

The strategies suggested involve the areas listed below.

Patient selection

Recruitment strategies included:

  • • 
    using existing groups such as women’s health groups,17 outreach programmes,21 prostate support groups,28 senior citizens’ employment services (‘rent a granny’31) and university YMCA women’s self-help groups;44 one study used a new group (a women’s health teaching group) to teach pelvic examination;7
  • • 
    advertising in newspapers or through posters;17,26
  • • 
    using existing training bodies such as women’s health consultants, including a private organisation which has conducted training in breast and pelvic examination since 1978,56 and Women’s Health Educational Consultants (WHEC), which has taught pelvic examination since 1971;37
  • • 
    purposive recruitment of subjects including paramedics,24 degree students,3,20 nurses and midwives,39,45,54 clinical staff8 and qualified educators,33 and
  • • 
    innovative methods such as using oocyte donors.23
Training of patient-teachers

Training of patients varied in duration from hours17,21,24,65 to weeks3,45 and involved training in teaching, assessment and providing feedback.

Sustainability of the training programmes

Some studies described payments made to patients at unspecified hourly rates,21,47 in euros per session6,73 and at $15 per session.44

Some studies provided estimated costs of running programmes at $50 per student,27$500 per GTA trained and $45 per student,3$20 per student for training using SPs compared with $40 per student for training using clinic patients,5 and $80 per student for a pelvic examination OSCE.49

One study discussed the logistics of running the programme and scheduling teaching to take place in the evening in order to suit working hours.15

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information

This review systematically evaluated 65 primary empirical studies carried out in the context of patient involvement in training in intimate examination skills in medical education. The review provides a summary of the rationale for and logistics of involving patients in this role and suggests strategies for resolving the practical issues that need to be addressed in order to bring the patient voice into medical education.

The main roles in which patients or volunteers were involved in intimate examination training were as teachers, or as informal assessors of clinical performance. This was best exemplified in articles describing teaching associates or programmed patients who allowed learners to practise their skills on them. Most of these patients were, in fact, healthy volunteers, who were motivated to train health professionals in intimate examination skills. One of the most positive elements of the evaluation of such programmes was that these teaching associates provided immediate feedback on performance, an attribute that cannot be expected from traditional methods of teaching using models or RPs. The employment of these patients in more formal assessment strategies, including as assessors on OSCEs and other forms of formative and summative assessment, was also described. In addition, the majority of teaching was conducted solely by these patients; input from health professionals related to the design of the programme, but not to the actual teaching. This represents a powerful model for empowering patients as medical educators and suggests possibilities for similar roles in other areas of medical training.

Educational interventions may be considered to be effective if they demonstrate beneficial outcomes. Most of the interventions involving patients as teachers of intimate examination skills were shown to have short-term benefit in terms of student and patient satisfaction and improvement in technical competence. These benefits were associated particularly with the facts that SPs can facilitate a non-threatening environment in which to practise examinations and can provide immediate feedback on performance. There is some evidence of the retention of skills on subsequent retesting and also for the increased likelihood that trainees will perform these examinations in practice after training by SPs. However, there is limited evidence of longer-term benefits of such training and of how and when reinforcement of training may be necessary.

The issues around ethics, sexuality and anxiety are addressed to a limited extent in the literature, either in the form of discussions prior to examination practice or by self-reports or actual measures during the training. These issues may influence students’ experiences of specialty placements and subsequent career choices. Training programmes may need to specifically target attitudes towards intimate examinations in order to allow health professionals to deal with their anxieties and increase their comfort levels when performing such examinations. The psychological impact of patient involvement in teaching intimate examination skills is less well explored. This has implications for the recruitment and retention of patients in this role and strategies to minimise any negative impact of becoming involved may facilitate the running of these courses.

From the review, there is little evidence of strategies to ensure the sustainability of such programmes and to indicate how they may be incorporated into the curriculum. There is also little exploration of the impact that the professionalisation of patients as educators will have on the doctor–patient relationship, the balance of power between the professional and the patient or the acceptance, or not, of public involvement in medical training. There is little evidence of a general structured use of patients for teaching all intimate examination skills. In most institutions, teaching programmes seem to be organised and evaluated by groups of enthusiasts rather than following institutional strategies for training in this important area of medicine.

The strengths of this review lie in its employment of a rigorous systematic review design which is consistent with guidelines and good inter-rater scores for analysis. However, it has some limitations. We believe that the review represents all studies published in this area during the designated time period. There is some overlap between the terms used to describe patients and standardised patients because the terms ‘patient-teacher’, ‘simulated patient’ and ‘patient-instructor’ are often used interchangeably and thus there is a chance that some keywords may have been missed during the search. Our limiting of the review to studies reported in the English language may have resulted in the exclusion of some studies published in other languages.

Conclusions

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information

There is strong evidence of the short-term positive impact of patient involvement in the teaching and assessment of intimate examination skills; however, evidence of longer-term impact is still lacking. The influences of sexuality and anxiety related to such examinations are explored to some extent, but the psychological impact on learners and patients is not well addressed. Further empirical research in this area should look at the feasibility, cost-effectiveness and sustainability of such programmes and objectively measure positive and negative outcomes for both students and patients.

Contributors:  all authors were involved in the design of the review protocol. VJ, ZS, NDQ and AA-H collected the data. VJ, ZS and NDQ analysed the data. VJ wrote the paper with help from ZS, NDQ, AA-H and TER, all of whom made substantial contributions to the final manuscript. All authors were involved in reading and amending the final document prior to submission.

Acknowledgements:  none.

Funding:  none.

Conflicts of interest:  none.

Ethical approval:  not required.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Conclusions
  8. References
  9. Supporting Information

Table S1. Journal study published in (n = 65).

Table S2. Types of examination described with teaching and assessment method.

Table S3. Effectiveness of interventions involving patients as teachers/assessors and common strategies.

Appendix S1. Search strategy for databases.

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MEDU_3608_sm_Appendix1.doc24KSupporting info item
MEDU_3608_sm_tableS1.doc31KSupporting info item
MEDU_3608_sm_TableS2.doc166KSupporting info item
MEDU_3608_sm_TableS3.doc86KSupporting info item

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.