Resolution: F-20-1: RESPECTING RELIGIOUS DIVERSITY IN PEER-PHYSICAL EXAMINATION COURSES

[Valerie Lile]

1  WHEREAS, Diversity embraces race, ethnicity, nationality, and gender and is expanding to
2  encompass sexual orientation, religion, disability, and more¹; and
3  WHEREAS, Respectful inclusion and diversity are integral to the well-being and effectiveness
4  of students, and are essential to delivering appropriate care²; and
5  WHEREAS, Studies show that students trained at a diverse medical school are more
6  comfortable treating patients from a wide range of backgrounds, in addition to having an
7  enhanced educational experience^3-4; and
8  WHEREAS, Studies show that increased diversity promotes positive attitudes in educational
9  and social environments⁵; and
10  WHEREAS, A study found that out of 106 medical schools, 30% utilized peer physical
11  examination, a method of teaching and learning clinical skills where students act as model
12  patients to allow practice of physical examination techniques, such as in osteopathic
13  manipulative medicine and clinical skills courses⁶; and
14  WHEREAS, Students may not want to be examined for various reasons that can include
15  religious reasons, childhood abuse or body image concerns and other reasons that should not
16  require disclosure⁷; and
17  WHEREAS, Religious students feel uncomfortable with the peer physical exams of intimate
18  body regions because of the association with sexual activity and strictly religious students are
19  significantly less willing to undergo examination of any body part except the hand^8-9; and
20  WHEREAS, 48% of end-of-first year medical students at the University of Minnesota felt
21  exposed when undressed in front of their peers for examination and 12% expressed difficulty
22  ensuring their consent was respected by peers¹⁰; and
23  WHEREAS, 99% of students were more comfortable examining a partner of the same gender
24  compared to only 70% of students were comfortable with a peer of the opposite gender¹⁰; and
25  WHEREAS, In these peer physical examinations, the student is playing the role of the patient
26  and has a right to informed consent where they can ask questions, express their concerns and
27  request alternative learning approaches¹¹; and
28  WHEREAS, Several ethical issues were identified regarding these physical examinations and
29  dress codes, which included feelings of coercion and a lack of respect for cultural and religious
30  beliefs¹²; and
31  WHEREAS, A study compared students’ clinical skills performance after switching from a peer
32  physical examination setting to utilizing standardized patients and found statistically significant
33  increase in the students’ grades¹³; therefore be it

1  RESOLVED, that AOA and SOMA work with appropriate stakeholders to develop inclusive
2  accommodation for religious obligations in peer physical examination courses which include
3  osteopathic manipulative medicine and clinical skills instruction; and be it further
4  RESOLVED, that AOA and SOMA encourage action by medical schools to provide sufficient
5  accommodations such as, but not limited to, the investment of privacy screens, same-sex or
6  selective partner pairing, and lenient dress code to be implemented in peer physical examination
7  courses in order to align with student consent and religious obligation.

Explanatory Statement

Inclusivity and acceptance of medical students is integral in establishing a healthy environment conducive for learning. Peer-physical examination courses, including osteopathic manipulative medicine, where students are required to act as the patient and be inspected by their peers, can oftentimes violate the students’ right to provide informed consent and also infringes upon many religious students’ beliefs. Many religious students are still required to partake in a specific dress code or partner with students of the opposite gender, despite directly conflicting with their modest and religious values. Medical students are left without options to opt-out or obtain accommodations, which hinders their learning and isolates them from their faculty and peers. In order to support diversity in our medical schools, we must address this issue and involve the necessary stakeholders to hold universities accountable for providing solutions and accommodating their students’ individual beliefs, so they are not conflicted between receiving a medical education and upholding their religious values.

Relevant Existing Policies:
H223-A/19 EDUCATION OF STUDENTS AND FACULTY ON OBTAINING PERMISSION BEFORE ALL STUDENT AND PATIENT ENCOUNTERS

H215-A/17 LONGITUDINAL APPROACH TO CULTURAL COMPETENCY DIALOGUE ON ELIMINATING HEALTH CARE DISPARITIES

H326-A/19 PROMOTING DIVERSITY IN AOA MEMBERSHIP AND LEADERSHIP

References:

1. Castillo-Page, L. (2010). Diversity In The Physician Workplace: Facts And Figures Association of American Medical Colleges, 11.
2. Roberts L. W. (2020). Belonging, Respectful Inclusion, and Diversity in Medical Education. Academic medicine : journal of the Association of American Medical Colleges, 95(5), 661– 664.
3. Rothman, P. (2006) Diversity In Medicine Has Measurable Benefits. org.
4. Whitla, D. K., Orfield, G., Silen, W., Teperow, C., Howard, C., & Reede, J. (2003). Educational benefits of diversity in medical school: a survey of students. Academic medicine : journal of the Association of American Medical Colleges, 78(5), 460–466.
5. Guiton, G., Chang, M. J., & Wilkerson, L. (2007). Student body diversity: relationship to medical students’ experiences and attitudes. Academic medicine : journal of the Association of American Medical Colleges, 82(10 Suppl), S85–S88.
6. Uchida, T., Achike, F. I., Blood, A. D., Boyle, M., Farnan, J. M., Gowda, D., Hojsak, J., Ovitsh,
7. K., Park, Y. S., & Silvestri, R. (2018). Resources Used to Teach the Physical Exam to Preclerkship Medical Students: Results of a National Survey. Academic medicine : journal of the Association of American Medical Colleges, 93(5), 736–741.
8. Koehler, N., Currey, J., Mcmenamin, C. (2014). What should be included in a peer physical examination policy and procedure. Sci.Educ. 24(4), 379-385.
9. Rees, C.E., Wearn, A.M., Vnuk, A.K. (2009) Medical students’ attitudes towards peer physical examination: findings from an international cross-sectional and longitudinal study. Adv in Health Sci Educ 14, 103–121.
10. Burggraf, M., Kristin, J., Wegner, A. (2018) Willingness of medical students to be examined in a physical examination course. BMC Med Educ 18, 246.
11. Chang, E. H., & Power, D. V. (2000). Are medical students comfortable with practicing physical examinations on each other?. Academic medicine : journal of the Association of American Medical Colleges, 75(4), 384–389.
12. Delany, C., Frawley, H. (2011). We Need a New Model for Obtaining Students’ Consent to Conduct Peer Physical Examinations. Academic medicine : journal of the Association of American Medical Colleges. 539.
13. Hendry G. J. (2013). Barriers to undergraduate peer-physical examination of the lower limb in the health sciences and strategies to improve inclusion: a review. Advances in health sciences education : theory and practice, 18(4), 807–815.
14. Ramey, J., Mane Manohar, M. P., Shah, A., Keynan, A., Bayapalli, S., Ahmed, T., Arja, S. , Bala A, S., & Acharya, Y. (2018). Implementation of standardized patient program using local resources in Avalon School of Medicine. Journal of advances in medical education & professionalism, 6(3), 137–141.

Submitted by:

Deena Abdelhalim, OMS II – Touro College of Osteopathic Medicine
Madeline Jentink, OMS IV – Chicago College of Osteopathic Medicine

 Action Taken: [Leave Blank. Will be Approved by the House of Delegates or Not Approved.] Date: [Leave Blank. Date submitted to National Vice President and the National Office.]

Effective Time Period: (If this resolution represents a permanent change, declare “Ongoing“. If the resolution is of a short-term nature, specify a date that this resolution could be removed from the Policies Section since the resolution would no longer be in effect.)

[JOHN HENDERSON<br>CUSOM]

This is a novel notion! I support the overall point being made here and applaud the authors for considering this resolution. I personally feel that students should be given more options for peer-examinations if they do not feel comfortable or do not give consent for any reason and that this reason need not be disclosed. In that sense, the second resolve statement is sufficient, but might be amended to specify that the AOA and SOMA should “address” rather than “encourage action” by medical schools to…, etc. Furthermore, the first resolved statement might be redacted or amended to clarify that the AOA and SOMA “address” rather than “work with” appropriate stakeholders…, etc. A “lenient dress code” in line 6 of the second resolve statement also needs to be clarified or amended to specify a dress-code that suites the wearer for religious reasons or other reasons of privacy. the Explanatory statement also needs some grammatical revision and wording that is less absolute, for example: “…also infringes upon many religious students’ beliefs…” might be better stated as: “…may also infringe upon students’ religious beliefs…”

Including SOMA policies S-19-11, S-19-18, and S-15-7 may strengthen their references, however, I feel the authors could go bigger with this resolution, for example: encouraging options should be the title and aim – perhaps change/amend S-19-11 (or use it as a background) may be a better approach, not just for religious reasons, but for others that relate to consent and that don’t need to be disclosed. Regardless, the authors have a strong foundational point to be made and have written something that I think medical schools should address for the comfort of their students.

I will address the whereas statements as follows:

– lines 1-2: reference 1 is an AAMC report from 2010, is an original source, suites the argument, but is not current.

– lines 3-4: reference 2 is a letter to the editor. A study may strengthen the argument here.

– lines 5-7: reference 3 is actually from 2016 (not 2006) and is not a study as suggested by the preceding clause and represents commentary and possibly an advertisement, suggesting bias. Reference 4 supports the claim and is original research, but might be strengthened by more current research

– lines 8-9: reference 5 is a questionnaire study of rising fourth-year students in mid-2003 at 3 medical schools in California, supports the preceding claims, but is not current

– lines 10-13: reference 6 is a good and current reference to support the knowledge that peer-examination is prevalent, however, the claim might be strengthened by research on osteopathic peer-examinations, as this is an overall argument being made

– lines 14-16, 20-22, and 23-24 and their supporting references do not necessarily address religion but do address the argument for the need for alternative methods of peer-examination due to students being uncomfortable. The references support some of these claims, but cite commentary and international studies, and do not address osteopathic examinations.

– lines 25-30 make claims that should be considered regarding consent, but rely on citations that might be improved as they reference a letter to the editor and a review by a single author, which may be irrelevant to its title (does not necessarily address undergraduate peer-examinations), and this argument.

– lines 31-33 are supported well with current, peer-reviewed research

Scoring:TOTAL: 70-73
– authorship: 0-3 – two authors
– clarity: 10 – some clauses do not directly address the religious reasons, but do add to a valid argument
– research: 15 – limited on original studies: some use of blogs, letters to the editor, commentary; and not all recent. Arguments are generally supported with little to no mention of osteopathic examination – most pertain to PPE/clinical skills. Whereas statements seem to move around a bit and may need more cohesion between arguments. The strongest argument focuses on obtaining consent and how uncomfortable students are with examinations, which supports the second resolved statement more than the first. A move to redact or amend the first statement might be warranted.
– scope/feasible: 20 – actionable, but questionably feasible by medical schools to comply in a timely way. Depending on the wording, it may or may not be within the scope of the AOA or SOMA
– novelty: 15
– fiscal note: 10

[Author]

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