Title : Joint effort: A repeated-cohort evaluation of a reverse-classroom musculoskeletal examination workshop using Peyton’s four-step approach
Abstract:
Background: Musculoskeletal (MSK) examination is a core clinical skill, yet medical students frequently report limited confidence in performing regional examinations. We evaluated a reverse-classroom MSK teaching programme combining bespoke video-based pre-learning with small-group practical teaching structured using Peyton’s four-step approach, and examined whether its effect was reproduced in a subsequent student cohort.
Methods: Final-year medical students participated in workshops delivered in 2024 and 2025. Bespoke pre-learning videos covered shoulder, elbow, hand, hip, knee, foot/ankle and spine examination. Face-to-face sessions used Peyton’s four stages of demonstration, deconstruction, comprehension and performance, with supervised practice and immediate feedback. Students rated their confidence in performing each examination before and immediately after teaching using a five-category ordinal scale (0–4). Pre- and post-workshop responses were individually matched. Regional changes were assessed using two-sided exact signed-rank randomisation tests with holm correction for multiple comparisons and matched-pairs rank-biserial effect sizes. Free-text feedback underwent inductive semantic thematic analysis.
Results: Forty-two students completed baseline questionnaires and 29 contributed matched follow-up data, producing 150 paired regional-examination ratings. Confidence increased in 127/150 ratings (84.7%), was unchanged in 20 (13.3%) and decreased in three (2.0%). Median confidence increased across all seven examinations, with all pooled comparisons remaining significant following holm correction (all adjusted p<0.001) and large rank-biserial effect sizes (r=0.85–1.00). At participant level, 26/29 students (89.7%) improved overall, three were unchanged and none deteriorated; median improvement was +2 confidence categories [I QR +1 to +2] (p<0.001). The improvement was reproduced across both the 2024 and 2025 cohorts. Qualitative feedback highlighted the value of structured pre-learning, explanation of clinical rationale, supervised practice, immediate feedback and a supportive small-group learning environment.
Conclusion: A reverse-classroom MSK programme incorporating Peyton’s four-step approach was associated with substantial and reproducible improvements in final-year students’ self-reported examination confidence. This model provides a practical framework for integrating preparatory resources with active clinical-skills teaching. Further evaluation should assess objective examination performance and longer-term retention.
