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The Associated Clinical Educators Role In Providing Feedback To Student Clinicians

 Associated Clinical Educators Providing Feedback To Student Clinicians

Last week saw us working online with our partners at Wolverhampton and Chester University. Although the role of the ACE is to work predominantly with helping the student to develop their physical skills with systems examinations, we also spent a lot of the time teaching them how to take an effective history.

Alfred Korzybski the developer of General Semantics once said:

“The meaning of communication is the response you get”.

When you are a medical professional sitting with an actual patient, you won’t be in the fortunate position of receiving feedback from them. They just won’t tell you.

They can’t.

They don’t really know what you are doing and you wouldn’t expect them too!

Working with an ACE or simulated patient changes all of that.

When ACEs work with students, their key role in the interaction is to provide quality feedback to the student clinician on their communication and the systems exam that they are performing.

Everyone employed by Meducate Academy are experienced actors and can therefore present powerful examples of a patient with a variety of problems and pathologies. Whether it be a mental health scenario, a difficult or challenging patient, an angry patient, those presenting with physical problems or working with colleagues and relatives of a patient. We have done them all!

This is all very useful as it creates a ‘reality’ for the student to work with, but it is not the complete story.

Role-play and simulation without high-quality feedback is just acting, and that’s not our aim here at Meducate Academy.

An ACE is an important and vital resource for the student, and our ability to recreate a scenario as a simulated patient providing feedback is of critical importance to the student and their assessors.

The feedback we offer allows the student time to reflect on their performance without the worry of making a ‘mistake’. That the environment is safe and that they can stop the scenario at any time in order to make any adjustments to their communication style.

You can’t do this with an actual patient!

Providing feedback in a nonjudgmental way gives the student an opportunity to improve without the pressure of having to get it right every time.

Feedback when given is always specific and detailed where necessary. We never say:

“Oh. That was Good!”

Without qualifying the statement to the student with detail as to why it was good and how it made the patient feel at the time they said it. Feedback should be evident and observable.

For example, the ACE would explain how the patient felt when the student failed to make eye contact when delivering bad news. There should be no ambiguity in your feedback, and clarity is vital:

“When you auscultated my chest and asked me to take deep breaths, you lifted the stethoscope off my chest before I completed a full breath cycle.”

This is much better than: “Keep the stethoscope on a little longer.”

The timing of the feedback is also important. We always wait until the end of the history and/or examination before giving feedback. This is normal unless the assessor/staff member asks for it earlier.

In some cases (mainly physical examinations) the ACE may stop the interaction if a procedure is performed roughly, or if the ACE is in danger of getting injured.

When we give feedback to more than one participant in a simulation, we keep it as succinct as possible and we never judge. An ACE will never compare one students’ performance against another. We take each person on their own merits.

When giving feedback, we do it in the third person as the patient. Explaining how the patient felt from their perspective is vital, and when we give feedback, we always ensure that we only make two or three points. We never overwhelm the student with a wealth of information, only enough to develop their skill set.

An ACE never gives feedback on the medical content of the simulation unless they have been specifically trained by a clinician. We always remind ourselves that we are lay educators and not clinicians.

If a student becomes defensive about feedback, we do not engage in arguing the point. Speak calmly and logically. A good structure therefore is vital. We are never too negative in our feedback and if the support of the facilitator is required, the ACE will get them involved.

If a student seems confused by the feedback, we take a few moments to reflect on what has been said and then recalibrate our communication style to suit the student. Everyone is different, and an ACE always endeavours to be a master communicator.

If a member of staff contradicts the ACE, we always wait till the session is over to discuss that difference in perspective. We would never discuss issues in front of the students. This may be an opportunity to learn something new and improve our skillsets.

It is often the case in our multicultural society that an ACE may not understand the student because of an accent, dialect or even the volume. We are always respectful, and will explain to the student that they sometimes have to work on this aspect of their communication in order to ensure they are understood and that their interaction has a high degree of clarity. Lack of clarity is always pointed out sensitively.

Sometimes the ACE may notice that the accepted dress code is not being adhered too. It is important that we highlight this in our feedback to the staff. Personal matters such as bad breath, body odour and unkempt appearance should be addressed. We don’t mention this directly to the student, but through the facilitator.

We always expect our ACEs and simulated patients to also develop their communication skills. We regularly assess them in this ability. Being an actor does not mean that you can be a role-player. The ability to deliver feedback effectively to the student is what is expected.

Let’s ensure that the standards of the ACE are as high as that of the clinicians.

We are currently producing a workbook for the ACEs and this will serve as a useful aide-mémoire for those who take on this very demanding but rewarding role.

Clinical Communication and History Taking – An Associate Clinical Educators Perspective

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:

  • Rapport
  • Behavioural Flexibility
  • Sensory Acuity
  • 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.

Interacting With A Patient Whilst Performing A Systems Exam Is Crucial To Building And Maintaining Rapport
Interacting With A Patient Whilst Performing A Systems Exam Is Crucial To Building And Maintaining 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.

Engaging The Patient Both Verbally And Non Verbally Is Crucial For Building And Maintaining Rapport
Engaging The Patient Both Verbally And Non Verbally Is Crucial For Building And Maintaining Rapport

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.

Meducate Academy Is Moving

Clinical training room at Wolverhampton University

Meducate Academy is moving, in many senses of the word…

Almost three years in the business and despite the impact that Covid-19 has created, Meducate Academy seem to be leading the way in the education of health-care professionals by Lay Clinical Educators and Simulated Patients.

The past week has seen us providing our services to one of our partners, The University of Wolverhampton. Under the direction of Pete Gorman Clinical Lead we supplied Associate Clinical Educators on their Physician Associate Programme. Working with three experienced ACEs we covered scenarios including the management of Mental Health issues, dealing with an anxious patient presenting with STEMI and a session on how to examine a patient with thyroid problems

These scenarios were designed to challenge the students both in their ability to take a focused history and a perform a focused cardiovascular and thyroid examination, including testing them on their ability to read an ECG correctly.

We ran the sessions as a mock OSCE over ten minutes, but unlike an OSCE we were able to give feedback to the students for twenty minutes each. The days were long but productive and very rewarding, plus the feedback given by the students was also excellent.

The students had worked with us previously, so they were not surprised by the level of challenge and the way we approach the delivery of Clinical Examinations. They were all PA students in their second year, so the pressure was put on them to perform at the highest level. Most of them didn’t let us down, and they thanked us for the work we had done last year.

Unlike volunteers and real patients, an ACE working alongside an experienced clinician can make a significant difference to the development of a PA student.

It is sessions like this that allow the students to make their mistakes in a safe and supportive environment. The ACE always gives feedback in a structured way, including information on the students ability to build rapport with the patient.

We will be following these sessions up next week with Mock OSCEs under actual exam conditions using seven of our most experienced ACEs. It should be an enjoyable week!

Next month we will also work with The University of Chester on their PA programme, but this time we will work online using Microsoft Teams. This is a different type of teaching and requires good camera skills. More of that in another post.

Working online presents us all with a variety of communication challenges. Lousy cameras, dodgy Wi-Fi and misunderstandings about how to use the system. The Internet can seem to have a life of its own at times. We have contingency plans for events like this.

We have even run online sessions to help students and our ACEs use the technology more effectively. Most of the online work we do focuses more on History Taking as it’s virtually impossible to do physical exams online.

Working online presents its challenges, but we have been working online since the start of the first lockdown back in March earlier this year. We more or less have it sorted!

Embracing the new technology meant we had to invest in state-of-the-art cameras, lighting and sound equipment to ensure that our customers get the very best experience.

It also means we can film training material and create Podcasts for use by our clients for future use when the Covid-19 pandemic is all over.

Those of you with a keen eye will see that our address has also changed.

We have now moved our offices from Shenstone in Staffordshire to a Birmingham city center location, situated at Grosvenor House in the Jewellery Quarter in St Paul’s Square. Having a central location makes it easier to train upcoming ACEs and meet potential clients. We are near to Central Station and on the major route into Birmingham from the M6.

All this and more to come. Including a proposed webinar where we invite senior Clinicians and Associate Clinical Educators together with students to talk about how to approach OSCEs. We are also currently filming and building a library of systems exams so students can have access to the latest examination methods being used in the OSCEs.

Thanks to everyone who has helped us make this journey.