Context: Peer physical examination (PPE) has been employed for several decades as part of the formal curriculum for learning clinical skills. Most of the existing studies exploring students' attitudes towards PPE are single-site and use quantitative methods. Currently, there is a lack of theoretical underpinning to PPE as a learning method. Methods: Using an adaptation of the Examining Fellow Students questionnaire, we captured qualitative data from Year 1 medical students about their views and concerns around learning using PPE. The study was set in six schools across five countries (the UK, Australia, New Zealand, Japan and Hong Kong). Students provided free text comments that were later transcribed and analysed using framework analysis. Results: A total of 617 students provided comments for analysis. This paper focuses on several related themes about the complexities of students' relationships within the context of PPE and their reflections on peer examination in comparison with genuine patient examination. Students drew parallels and differences between the peer examiner-examinee relationship and the doctor-patient relationship. They explained how these two types of relationship differed in nature and in terms of their levels of interaction. Discussion: Our findings illuminate the interactional and complex nature of PPE, drawing out concerns and ambiguities around relationships, community and rules. We discuss our results in light of Engeström's model of activity theory (AT) and provide recommendations for educational practice and further research based on the principles of AT.