Working on the Physician Associate Programmes as an Associate Clinical Educator is always a pleasure. It’s an even better experience when you give a new ACE an opportunity to spread their wings and fly solo for a day. They are the lifeblood of the organisation, after all.
This week we gave one of our new ACEs the opportunity to work with us at the University of Chester on the PA programme. We also gave a potential ACE the opportunity to shadow another experienced ACE before being let loose on the students.
We were tasked with assisting in the teaching of Musculoskeletal Examinations: Hands, Feet, Shoulders, Knee and Hip, with the help of clinical Lecturers Jack and Alice, who had prepared the students with an earlier lecture.
I particularly enjoy the MSK sessions and as I have some significant pathologies myself. This gave the students the opportunity to work with someone with real musculoskeletal problems, and also able to give feedback to the students on their examination technique.
Teaching in the skills suite next door was Greg Hobbs, a trusted and highly experienced Associate Clinical Educators. He was being shadowed by Vikki one of our newly trained ACEs.
I was in the main skills suite with Howard, one of our new ACEs, who was now being given an opportunity to show me and the clinicians what he could do. He never let me down and his understanding of motivational interviewing techniques also allowed him to help the PA students sharpen their communication skills.
All of our Associate Clinical Educators are highly experienced communicators before they embark upon our ACE training programme. This is one of the main criteria for the role.
Clinical skills are important, but so are communication skills, and we pride ourselves on being able to give structured feedback to students about both elements of their interaction with an “expert patient”.
We always give the groups a small demonstration of the examination being taught, then we let the students get hands on with the ACEs as soon as possible, making sure everyone engages with the lesson for the day.
Keeping the students engaged is another skill we are very good at. All of our ACEs have performance based training backgrounds and are trained actors, and know how to keep an audience focussed on the performance. This is an important but often missed aspect of clinical teaching and is not something that is taught to clinical educators normally.
We believe that it is important for the students to have a light hearted approach to the training. Learning should be enjoyable and not be a chore.
Next week is revision week at Chester University, so three of our experienced ACEs are up there again to help the students prepare for their Mock OSCEs, another aspect of the important role we play.
If you have enjoyed this post and want to learn more about how we can add hi-fidelity simulation with structured feedback to your students and institution, why not come online on the 4th September 2021 at 12 noon and listen to 6 clinical leads talk about their experience of working with ACEs and Meducate Academy. It’s free and you even receive a free hardback, soft touch notebook in the post!
My journey as An Associate Clinical Educator started way back in 1984 when I enrolled on the Drama and Theatre Arts Degree course at The University of Birmingham. It was a massive departure from my previous life back in the North of England. I was a mature student and at least ten years older than my fellow students, and the real challenge was also having two small children in tow! The course was the best thing I could have done and has changed my life immeasurably.
I would never have imagined that many years later I would work as an associate clinical educator at the same university but this time in the Medical School and not the Drama department.
After qualification I was working as an actor in TV, Film, Theatre and Motion Capture. I served a fifteen year apprenticeship as a comedian on the alternative comedy circuit through the late 80s to the early noughties as part of a double act.
It was during my time as a comedian that I was able to develop skills as an performer and spent this time persuading the audience that we were funny. Working as a live comedian is the best place to learn to deal with an audience. If you don’t get your message across, you are told to “Get Off”. Not usually as politely as that!
In the background to this I was also building my skills as a corporate educator, motivational speaker, and a Trainer of NLP (Neuro Linguistic Programming). NLP is something I continue to be involved with to the present day.
In 2009 I changed direction and applied to be a Medical Role Player with The Interactive Skills Unit (ISU) at The University of Birmingham. This required a different set of skills and as well as acting I was also expected to give feedback to the medical students after having role played various scenarios with them. A different way of working for me, and I enjoyed it immensely.
It was during a GPVTS roleplay session that the Manager of the ISU, Karen Reynolds, approached me and asked if I would be interested in working as an ACE. This was a role developed by Professor Jim Parle of The Physician Associate Programme at Birmingham. I jumped at the chance and embraced this new venture. It would shape the course of my future career working with health professionals.
With the help of Jim Parle I embarked upon my new career as an ACE. It meant I could combine my skills as a communicator alongside my new growing knowledge of body systems examinations. Giving feedback on the students technique as well as their communication skills. I could now help the student on two levels. Having been a trained engineer in the 70s I took to the role easily, as body systems are not dissimilar to mechanical systems. I also took this approach whilst studying anatomy and physiology.
Over the next six months I bought books on body system examinations and practiced the techniques with Mark, one of the other ACEs. Together we made a formidable team and worked with The Physician Associates and their Clinical staff. The clinicians were always supportive of our efforts and always made us feel part of the team. They gave us insight into the methodology of examining the CV, respiratory, GI, cranial nerves, upper and lower limb neurology. We also helped the students’ approach to sitting the OSCEs (Objective Structured Clinical Exams). We were learning on the job and I spent many hours pouring over medical textbooks to enhance my knowledge in my own time.
In 2011 I was offered a chance to learn examinations of the musculo-skeletal systems, working for The Royal Orthopaedic Hospital (ROH). Training was carried out by Consultant Surgeon Mr Edward Davis and Consultant Physiotherapist Andy Emms. These sessions were well structured, theoretical and practical, and they guided us through the hip, knee, shoulder, spine, hand and ankle examinations in great detail along with supporting materials. This would be another string to my bow.
As time went on, I was fortunate to work with some great clinicians who were always happy to help and answer my questions. Some have even become friends as well as colleagues.
I now have the pleasure of extending my knowledge to other universities and institutions and find myself able to offer employment and training to other role players and actors wishing to embark on this amazing career.
I am also in the process of creating a course with a view to ACEs gaining accreditation for the role through one of our partners. I believe this is vitally important in maintaining high standards of teaching to the medical students. Many of the clinicians I have worked with over the years have offered their help in teaching new ACEs to the very highest level.
Who would have thought it would have come this far? It’s thanks to the people who gave me the opportunity to reach out to students and help them on their journey to becoming great clinicians.
The recent pandemic saw a downturn with employment in the field for many role players, but I was able to take up this challenge and run with it. Working in conjunction with Peter Gorman at The University of Wolverhampton and James Ennis at Chester University, we were able to teach online and take OSCEs from March 2020 right up to the present date. Thus ensuring the students had as little disruption as possible to their studies. Sadly, some universities did not embrace this way of working until much later. We were therefore ahead of the curve in adapting to the changing working environment and I was able to offer employment to some of my friends and colleagues.
It is during tough times like this that I fully realise the significance of one of my lifelong maxims:
There is no Failure. Only Feedback.
If 2020-21 was anything to go by, 2022 promises to be an exceptional year for Meducate Academy. This is how I see the future.
If you, like me, fancy a real challenge, come work with Meducate Academy and join us on the journey.
Feedback is important to the student and is also of importance for us to receive feedback on our performance. This is a vital part of the communication interaction and helps us improve our facilitation skills.
At Meducate Academy we always want to hear what the student thinks of the session and we often ask them to appraise our performance and give us feedback, and it’s always nice when that feedback comes in the form of a testimonial that you just didn’t expect.
Last week we were lucky enough to work with the 2nd year Physician Associate cohort at The University of Chester. A very highly motivated group of students who show real promise. We were assisting clinicians in teaching MSK and general systems examinations, and the day went well.
There were six ACEs teaching all day and each group broke off into their separate rooms, observing the current Covid-19 restrictions. The students were able to take histories and then perform a physical examination. We then asked them to report their findings (if any) and give a summary and management plan.
I was happy that everyone performed well (including the ACEs) and we left Chester in high spirits.
Our return journey to Birmingham gave us a chance to reflect on our performance and that of the groups we were working with, and we all felt that the day had gone well. Self-reflection is an important part of the process for all Meducate Academy employees and allows us to develop our skills to the highest standard.
Within 24 hours some students had put a post up on Instagram and I felt I had to share it here on the blog.
We are currently working on writing a manual that will help students pass their OSCEs. This is in partnership with a senior clinician from The Royal Orthopedic Hospital. It’s aim is to give two different perspectives on the OSCE process. The first is from the point of view of the ACE/simulated patient and the other from the examiners perspective. We believe this is the first time anything like this has been published. As ACEs and simulated patients we have been involved in thousands of hours of OSCEs which in-turn gives us an insight into how students can improve their performance. Keep your eyes peeled for this in the near future.
On a similar note Matrix Education has produced Primary Care For Physician Associates, an excellent reference source for the training of physicians associates which is available now. One of the authors, Sofia Hiramatsu, was an old student of mine at the University of Birmingham medical school. She is now a successful PA working in London and founder of Matrix Education. I am particularly proud of her achievements in the field of medical education. At over 600 pages, this book will be a useful aid to not only help you pass your exams but also serve as as useful aide memoir when you are qualified as a Physician Associate.
It’s always important for an ACE to understand the protocols health professionals must follow to help them take a good history from a patient. Once we understand this we are able to give hi-fidelity feedback to the Clinician and thus help them improve their ability to build rapport and gather information simultaneously.
Last week I had the pleasure of working with our partners at The University of Chester and The University of Wolverhampton Physician Associate Programmes.
At Chester University we worked with 1st Year physician associates and at Wolverhampton we were working with 2nd year students. In both cases we were looking at how students communicate effectively with patients. What was apparent is the importance of quality feedback to the student.
For the students at Chester this was their first time looking at role-play, it was difficult convincing shy students to step up to the plate and hear their thoughts. It turns out that the ACE also has to be something of a motivator encouraging the students to take part. To get to grips with the scenario and to see that “roleplay” can be fun and educational, rather than scary and intimidating. It is this element of teaching that I particularly enjoy.
Wolverhampton however was very different, but still had its challenges. Although the students were more experienced with role-play and history taking, we still had a lot of work to do as the scenarios were far more challenging.
This week however, they had a reprieve from taking part in role-play.
I had been asked by the clinical lead Pete Gorman to deliver a session on communication theory and to talk about the practical challenges students face when talking to a difficult patient.
Whenever we communicate we interact both verbally and non-verbally, and understanding how we can make this work would take more than this short article. Here is a brief synopsis of what we discussed.
There are four legs to effective communication and these are:
Knowing your Outcome
Rapport is key to successful communication. Indeed without rapport it is very difficult to influence anyone, whether that be to make behavioral change or to take a simple history. We have all had that experience with another person when we feel we just connect. We sometimes find ourselves engaged in a conversation with a stranger and feel that they are just like us. That is rapport. People deeply in love have rapport to the extent that they mirror each others’ posture, language and even breathing patterns. That is rapport.
In order to be effective in our communications with patients we must also be aware of the continuous process of feedback. It is important to know whether we are getting what we want from our communication. To do this effectively we must have sensory acuity. We notice changes in physiology, breathing, eye accessing and language patterns. Armed with this information we can build rapport more authentically and deepen the relationship with the patient.
Once we have noticed these seemingly imperceptible cues, we can help the patient make better decisions and connect fully with the health professional. Using these tools will allow the clinician to help the patient to have a greater awareness of the choices available to them in the present, rather than have these choices restricted by past experiences and out-dated responses. This is what we sometimes call motivational interviewing.
Finally, everything you achieve is an outcome. If you are successful in your endeavours; that is an outcome. If you don’t succeed, that is still an outcome. Whatever we do results in an outcome. In order to achieve desirable outcomes we need to effectively model what works and then go out and do it! Rehearsal through role-play is the key to achieving positive outcomes when taking a history. You will always get what you ask for! Ask in the correct way and you will achieve your goal.
Whilst all of the above should be noted there are other important considerations that a clinician should be aware of in history taking.
I asked the students to remember the following when taking a history.
Presenting complaints – This is a list of the main symptoms or problems.
History of presenting complaint – This is an in-depth description the the presenting compliant.
Previous medical history – This is a comprehensive list of the all the illnesses, conditions and operation the patient has had in the past.
Drug history – A list of all of the patients medications and any allergies they may have.
Family history – Ask about conditions that run in the family.
Social history – This includes information about home, occupation, hobbies and habits. This would include smoking, drinking and illicit drug use.
Systems review – This a checklist of closed questions for every organ system in the body.
Using open and closed questions is an important skill. Closed questions at the start of a consultations encourage short yes and no type answers. Not good for building rapport in the opening stages of a meeting. Open questions encourage the patient to talk and that can be useful. Save the closed questions for gathering a quick response.
A common question I get from students is what factors hinder good communication? The list is extensive and I’ve seen and heard them all, but here are a few.
A badly worded introduction where you don’t clearly say your name. Not remembering the patients name, embarrassment, lack of curiosity, not asking the right types of questions, not making the right amount of eye contact, misreading body language, making assumptions, not listening actively, missing cues, not knowing how to deal with an answer, an over talkative patient, misunderstandings, making assumptions about the patient, stacking questions, judgemental behaviours. There are so many!
At the end of the session I gave students strategies to go away and practice. We always have opportunities every day to practice our communication skills. Unless you’re a hermit of course!
Check out the interactions between Mark and Bob on the video and if you are an actor interested in becoming a medical role-player and want to take it to the next level get in touch and join our growing ACE team. We will be posting dates for the next ACE training soon.
One of the greatest innovations the computer age has brought us is the opportunity for anyone to set up a podcast. Podcasts are great to watch or listen to when you are on the move and allow you to get information quickly from a variety of sources. We at Meducate have embraced that technology and are now producing a series of podcasts on Medical Roleplay and Associate Clinical Education (ACE). We will be talking to clinicians and simulated patients and, in some cases students, about their experience of working with us.
Last week I interviewed James Ennis, Clinical Director of the Physician Associate Program at Chester University, who I have had a working relationship with for over 10 years.
You can listen to the podcast here, but I thought it would be good to give a very abbreviated version as a blog post for those who don’t have the time to listen.
BOB: Welcome to the Podcast, James. First of all, thanks for coming on and agreeing to do this. I know you are very busy dealing with a multitude of challenges at the moment, but I’d like to get your view on what it’s like to work with medical role players and ACEs in this ever changing environment.
JAMES: Thanks, Bob. It’s a pleasure to talk to you about this subject and get it out to a wider audience. As you know I’ve been working with Associate Clinical Educators and role players for the best part of 10 years and we’ve always had them within our curriculum both at Birmingham University and now at Chester. I think it’s an important aspect to medical education, and the feedback we receive from students about the experience is always exceptional. I’ve never once had negative feedback from a student regarding clinical educators or role players because of their ability to help the students relax and also give them constructive feedback about both their physical examination skills and their communication skills. It’s often the case that students can feel more anxiety when working with an academic clinician than with an external educator such as an ACE.
BOB: Yes, I’ve noticed how much more relaxed the students are with us and I guess it’s because we come in at their level in many ways and with our knowledge of systems examinations we can help them practice their techniques quickly and effectively without recourse to in-depth academic analysis. It’s hands on without too much theory, which a lot of students crave.
They really enjoy the hands-on skills we help them with, and even simple techniques like palpation and percussion are keenly rehearsed with us over and over. Sometimes it’s the simplest things that can cause the most confusion and we are there to hold their hands, as it were.
I was obviously trained by Clinicians like yourself, but the students often comment on how knowledgeable we are in terms of our understanding of the examination process. We are also able to tell whether the student is gaining rapport with the patient and handling the patient in a respectful way. That and of course our extensive understanding on what is expected in OSCE’s.
As an ACE and role player, I and my colleagues must have been through 1000s of OSCE stations in our time. We have a good idea what an examiner is looking for, and this gives us a lot of credibility when students ask about OSCEs. It’s one of their big concerns, and having this knowledge helps us build trust with the students.
JAMES: Yes, I’ve noticed that when we work with you guys, you have this knack of reading the whole situation and responding appropriately. The fact that you have background knowledge of history taking and Systems Examinations, as well as a clear understanding as to what’s required in the OSCEs, has been tremendous in improving the students ability to, not just pass exams but turn out as very good, very safe clinicians. The feedback you guys give about excessive use of jargon is also important and can sometimes be missed by volunteer patients, for example.
Consulting with simulated patients when it might be called upon for them to perform intimate examinations, are made so much easier when working with an experienced ACE. That ability to help the student keep their sense of humour and deal effectively in a relaxed manner in what could be a very embarrassing situation.
Like I said you guys are an invaluable resource. I don’t know how you how you found it over the years, but I think it’s grown into something far more meaningful than we ever thought it would be.
BOB: Obviously you have embraced the idea of using ACEs as part of your teaching methodology and you find them of great value in consolidating the students learning. Yet, there are only a few institutions that utilise our skills. Chester, Wolverhampton and Birmingham are the three I know of. Why do you think ACEs have not been used elsewhere, bearing in mind the high value you place on them?
JAMES: Ultimately if we’re going to be completely honest, I think a lot of it comes down to money and resources and availability, which is a real shame, because as we know working with ACEs really embellish and enrich the student experience, and we have both alluded to the fact that ultimately students retain information and learn faster when examining real people. People who can give extensive feedback in a structured way and link that to the real world. We were even talking about getting the ACE role validated, which I know you have been a keen advocate of. That would be icing on the cake as it were.
BOB: Yes, I for one would be very keen to have the role validated. I think academics would take us more seriously and once they had experienced working with an ACE, would then realise the value and they would then add is to their program.
JAMES: Absolutely. We’ve spoken about this in the past and I think it needs to be a requirement and there is an important need to have some accreditation process or some monitoring, because it is actually a very robust system.
Academics who have not experienced working with an ACE might not be aware of the amount of training that goes into being an effective ACE, and I have seen the type of preparation ACEs go through, both as individuals and as part of the team. That’s the other aspect that needs to be mentioned. When you work with us at Chester, you really are seen as part of the team and are treated as such.
BOB: Yes, that’s true. We feel valued as much as other external educators, and we do appreciate it. It makes for a smooth working relationship and I think the students notice this too.
The recent Pandemic must have posed challenges for you as an educator and I know it has affected the amount of work we have had. Some Institutions were up and running, but most seemed to struggle with embracing the new idea of working online. What was your experience like?
JAMES: Yeah, that’s a good question, actually. Obviously, we have had to change our approach to clinical practise and there have been significant changes in general practise in the community. We have had to work with video conferencing, telephone triage and consultations and we have found new ways to use these technologies with you guys at Meducate.
In fact, you were up and running as soon as the lockdown happened. This was great news for us, as we could use your services almost immediately and the skill and depth of understanding you brought to this new way of working was refreshing. Everything ran like clockwork. I can only say thanks and say that for those reading this Meducate can provide you with an excellent and very professional service.
I would like to thank James for giving permission to abbreviate our podcast and in future posts will include more interviews with clinicians as well as ACEs and students.
It’s true to say that during the Covid – 19 crises our services have not been required as much as normal. Whilst many institutions seem to be struggling to embrace online teaching some have risen to the challenge and hit the ground running. We have been fortunate however, working with both Wolverhampton and Chester Universities on their PA Programs. This is great news as it helps keep our skillsets sharp and allows us the opportunity to embrace this new way of working.
Teaching online does have its challenges but I find it as easy as if we were working face to face with students in a classroom. The feedback we have received from students has been excellent and this gives us confidence that what we are doing is hitting the mark.
Working with students directly, and in particular with Physical examinations, has not yet been possible due to social distancing. This will change soon with September seeing us back in the driving seat working as ACEs.
Many ACEs and role players are also trained actors which obviously ensures that scenarios are realistic and believable. We often get feedback from students saying how “real” they felt the interaction was, and because of our varied skillsets we often get asked to make training videos. These, more often than not, see us in consultations with us acting as patients, who might have challenging behaviours, as well as physical conditions and a comprehensive history.
Last week, we had a opportunity work with the Chester University PA Program when we were asked to take part in a filming session for James Ennis the Clinical Director at Chester University. We were tasked with developing a training video demonstrating a variety of typical Musculo-Skeletal Examinations (MSK).
We have been trained in clinical MSK examinations over 10 years ago by Professor Edward Davies (Consultant Surgeon) and Andy Emms (Consultant Physiotherapist) of the Royal Orthopaedic Hospital in Birmingham. This means that our level of skill and knowledge of how to prepare the students to perform these examinations is text book.
We often help prepare PA students and 4th Year Medical Students when working for The University of Birmingham Medical School in MSK examinations and this has sharpened our skills. This experience has been invaluable to our education as an ACE, as well as us being able to take advantage of online resources that are readily available if you know where to look.
The requirement was for us to go through complete Hip, Knee, Shoulder and Lumber Spine examinations, which also included Upper and Lower Limb Neurological exams.
With the help of Scott Howard from simulation, we managed to film all of the sequences and we look forward to seeing them being used by all those on the PA program in the near future. What made it even more useful was that we were able to review our knowledge base, and have an opportunity to practice skills we have not used for 4 months. It was a win-win situation!
I was assisted as always by my travelling companion Mark, who made the journey up to Chester pass by in the wink of an eye.
If you want to find out more about the role of the ACE and how we can help your students improve their technique, contact is at Meducate Academy.