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Building Rapport and Maintaining Empathy In Challenging Scenarios

Demonstrating the role of the ACE to a group of 1st and 2nd year Physician Associates

Meducate Academy were recently invited down to The Drummond Education Centre West Suffolk Hospital to demonstrate the role of the ACE to a group of 1st and 2nd year Physician Associates. The vast majority of the day was spent taking the students through systems examination techniques. Many of the students requested that we discuss techniques dealing with challenging patients, building rapport and maintaining empathy under stressful conditions.

During my time as an ACE, I inevitably get asked these types of questions from both students and novice ACEs. Questions usually focus on:

  • How do I deal with an angry patient?
  • How do I deal with contentious issues?
  • How do I deal with upset patients?
  • How do I break bad news empathetically?

Although each situation may present with its own problems, there are a few rules you can abide by which will help achieve the desired outcome.

When we talk about communication, the phrase that always crops up is:

“How do I build rapport and create empathy in a challenging scenario?”

Sometimes, when you are under pressure to deal with (for example) an aggressive, angry patient, it’s not so easy. Stress will cloud your judgement, you will doubt your ability to communicate effectively. You may panic, or at worst display anger of your own!

The first thing you should do is acknowledge the person’s situation. Acknowledge how they are feeling. Begin by asking them for more information about the source of their anger and then listen! If they use words like angry, frustration, annoyed, upset, use their words when replying to them, for example:

“I can see that you are angry.”

“I can see that you are frustrated… How can I help?”

Do not interrupt the patient. Wait for a natural space that they will create. Recognise how they feel without judgement. You must then explore the situation that has caused the anger, the frustration.  Get them to define and clarify what they mean when they say they are frustrated.

Listen – Listen – Listen.

Whilst you are listening, use minimal encouragers. These are little verbal or non-verbal cues to show the patient that you are listening. For example:

Nodding of the head.

Saying, “Mmmm.”

Saying, “Go on, or yes.”

When I say listen, you must actively listen and not wait for the patient to stop talking, so that you can throw in a question that has no relevance to the patient’s current situation.

New students have a list of things they must ask the patient. SOCRATES is one of them and of course there is ICE (Ideas, Concerns, Expectations). Whilst these are important to complete a consultation, use them in the context of the situation. This is a conversation, not a battle or a debate. Become a partner in the interaction.

Once you have found out what the source of the problem is, it is time to restate what the patient has said. You could even say: “Is that everything?”  Restate what they have said and get acknowledgement. You are now both talking on the same page and you can now help them come to some sort of closure. You are thereby maintaining rapport.

Meducate Academy teaching key concepts of the role of the ACE to Physician Associates at The Drummond Education Centre West SuffolkDuring any heated conversation, you must think about your body language. Do not be too defensive in the way you are sitting or standing. To a certain degree, you need to mirror some of their nonverbal language. If they are in an open posture, keep yours as open as possible. If their arms are crossed, cross your hands or maybe your legs. This is called micro-mirroring and is less obvious to the patient.

You may also notice that some patients use words that sound visual, auditory or kinesthetic. It’s important to listen for these types of words. Below are some examples of sensory language or phrases that are commonly used.

The patient might use words or phrases that describe their experience visually:

“It’s clear to me.”
“I see where we are going.”
“The future is bright.”
“Look at it this way.”

They might however talk about:

“Getting to grips with the situation.”
“Trying to get a handle on things.”

These are kinesthetic statements and again you must learn to listen for them and use similar types of language in your reply.

Finally, we have the auditory pattern:

“I hear what you’re saying.”
“You are not listening to me.”
“Does that click for you?”

Often, people will use one or more of these sensory based patterns when speaking. Mirror some of these patterns and you are on the way to creating trust and rapport. Using the patient’s verbal and nonverbal language is a powerful way to build trust and hence come to an agreement.

Finally, never jump in mid-sentence when your partner is speaking. Keep listening and if the patient pauses, wait a little longer as they may be reflecting on what they have said. I often tell a student to bite their tongue and count to five before speaking. Give the patient time.

It is your responsibility to find out what the patient is trying to say. If you don’t understand what the patient means, ask them, for example:

“Would you explain what you meant by that?”

“I’m sorry, that’s unclear. I’m not sure what you said. Can you help me understand?”

If you are a student PA reading this, use these ideas to generate powerful, meaningful conversations with your patients. If you are an ACE, these techniques are the tools of your trade, so it’s your responsibility to be aware of them. You need to help a PA student to recognise them too.

If you are a Clinical Educator and would like to take advantage of using ACEs as part of your clinical teaching, book now for a free consultation. Contact us via the form below or give us a call on 07870611850. Thanks again for reading this post.

Meducate Academy – Five Years Of Providing Student Centered Medical Simulation

Meducate Academy has been providing student centered educational services now for five years. Five exciting years of ups and downs but mostly ups!

When we established the Academy in 2017 the world was a very different place, pre-Covid, when every thing looked brighter. We had established ourselves with two growing University departments. Wolverhampton had only just recommenced their Physician Associate Programme under the leadership of Gill Conde and Pete Gorman. It was going from strength to strength.

Meducate Academy ACES at The University of Chester Medical School
Meducate Academy hard at work at The University of Chester Medical School

Chester University was also using our Associate Clinical Educators across their programme under the guidance of their new Clinical Lead James Ennis. Things were going well and growing rapidly. Who could have guessed what would happen next.

The Pandemic came as something of a surprise to everyone and things started slowing down for most educational institutions. Some closed their doors and didn’t start up again until twelve months had passed and things for us looked bleak.

Simulation means being in front of students. Face to face interaction and hands on physical examinations which were the norm had all but ended for everyone.

Undaunted, we took the bull by the horns and started working online with history taking skills, and even had an attempt to run a pilot of online OSCEs. It was a creative time for us and our partners, and we learned a lot during that period. We adapted and improvised and came up with innovative new ways of teaching online and used a variety of different technologies to further our cause.

Once restrictions began to lift we were back to work but this time in full PPE, taking the students through the preparatory work on systems examinations in preparation for their OSCEs; and it worked. Students were keen to get back into the sessions and Chester and Wolverhampton Universities led the way. Whilst other Institutions were using mannequins, we were back at it. Cardio, respiratory, G.I. Cranial nerves, Neurological, and of course MSK examinations were being practiced almost as normal.

Teaching and support for the students was second to none and we were able to carry on almost as normal. It was for us a good time and now that the situations is getting back to normality we are being approached by a number of institutions to supply Associate Clinical Educators on their Programmes.

In the above video we listen to Bob (Founder and Director of Meducate Academy) and Senior ACE™ Mark Reynolds about what’s been happening and how Meducate Academy is shaping up for the next 5 years.

If you are a Clinical Educator and would like to take advantage of using ACEs as part of your clinical teaching, book now for a free consultation. Contact us via the form below or give us a call on 07870611850. Thanks again for reading this post.

Diversity & Confidence Building In Medical Simulation

Demonstration of MSK skills at The University of Wolverhampton

The past month has been frantic! Both of our partners (Wolverhampton and Chester University) have kept us busy with both their 1st and 2nd year cohorts. We have sent teams of ACEs out, providing hi-fidelity teaching and simulation covering a number of body systems. The teaching included reviews of both their communication and history taking skills. So far the topics we have covered are Cranial Nerves, Cardio-vascular, Gastro-intestinal, Respiratory and scenario based training.

In the next few weeks we will also be teaching upper and lower limb neurological exams, as well as intimate examinations on males and females. We have access to specially trained ACEs for this type of examination. Obviously when students perform these types of examinations there is often a degree of embarrassment on the part of the student. Our ACEs are highly experienced in allaying any fears the student may have, and this creates a safer and confident approach when examining a real patient. Most medical institutions don’t offer this type of experience to their students and often rely on using mannequins to practice their skills on.

Our connections to other institutions continue to expand and we are currently in talks with a couple of universities who have expressed an interest in what we are doing. We have recently been involved in MMIs for the recruitment of medical students at The University of Chester.

It still amazes me at how adept our ACE™ team can be. They are able to switch systems examinations at a moments notice, improvise around a theme and yet still provide high quality feedback to the academics and clinicians who are teaching on that module. It is experiences like these that have prompted me to write this month’s post. Without wanting to sound repetitive and simply repeating the last post, I think institutions and individuals are starting to realise the difference between an ACE™ and a simulated patient.

In a few weeks you will have the opportunity to listen to Mark and myself talk about the ACE™ role with James Catton from the PA Podcast. He was somewhat surprised at the level of our knowledge of body systems and was under the illusion that we were simply simulated patients and role players. He was so impressed with our expertise that he is in the process of organizing workshops with the University of East Anglia and Anglia Ruskin University Cambridge Campus.

So, coming back to our team of ACEs and their diverse range of skills, let’s look at a typical month of Meducate Academy’s workload.

Cranial Nerves Examination with Clinician Jack and ACE Howard (Seated) at The University of ChesterIn the last month we have worked with students to improve both their clinical and history taking skills. This was done in the context of both OSCE practice and when they are out on placement where they are expected to use a hybrid approach. We also worked with an experienced Physician Associate in a GP Practice, helping them with their time management and trouble shooting skills. This demonstrates how diverse our ACEs can be when required.

Our skills were also required in order to help pharmacists with their clinical examinations. This was for an assessment to help them gain their Independent Prescribing Course qualification. The pharmacists were given the opportunity to practice their examination skills in a safe environment with ACEs who gave feedback on their techniques. Techniques such as percussion, palpation and auscultation. We helped them work through the seven main body systems whilst the clinicians present talked about the common pathologies they would encounter.

Skills such as these can be practiced with a volunteer or even a sim-man, however what the students don’t get is high quality feedback. This is the main strength of our approach to teaching and the key to our success. Knowing the moves is not enough. The clinician must be able to perform these skills correctly and with our help, through educated feedback, become excellent, safe clinicians.

The body systems covered in the past month have included G.I, respiratory, cardio-vascular, cranial nerves as well as a whole range of neurological exams. We also covered history taking scenarios and the practical aspects of examining a diabetes patient, and how to examine the thyroid.

With the 2nd year Physician Associates we were able to guide them with multiple systems reviews working in a hybrid way. Just like the real world of medicine.

Happy team of Associate Clinical Educators Greg Hobbs, Ellie Darville, Howard Karloff & Meducate director BobOn top of all this of course is the ongoing conversations we have with the students about their fears and worries about the intensity of their course. The students always feel that they can talk to us more openly about their fears rather than going to the academic tutor. This takes some of the pressure off the academics who already have a full timetable. In the 12 years I have been an Associate Clinical Educator I have spent many hours helping students build their confidence and motivation through a variety of strategies.

Knowing that students will confide in you and seeing them graduate is the most rewarding part of the job and the reason I do this work. It’s a role I would recommend to anyone who enjoys working with the medical profession. It’s our way of giving back to the NHS in a small way.

Also, we have finally organised the accreditation process for the ACE™ role and will be running a pilot of this at the University of Wolverhampton in May 2022 with Professor Jim Parle.

On top of all that, a few weeks ago I was called into Trinity Court GP surgery in Stratford-Upon – Avon to run a workshop to 25 staff about how to deal with conflict in the workplace!

Now that’s diversity.

If you are a Clinical Educator and would like to take advantage of using ACEs as part of your clinical teaching, book now for a free consultation. Contact us via the form below or give us a call on 07870611850. Thanks again for reading this post.

An ACE™ Is Not a Simulated Patient, But A Simulated Patient On Steroids!

1st Year Physician Associate Students and Associate Clinical Educators at Wolverhampton University

Recently my attention was drawn to an article, ‘It’s Not An Acting Job … Don’t Underestimate What A Simulated Patient Does”: A Qualitative Study Exploring the Perspectives of Simulated Patients in Health Professions Education”, which was submitted to the journal of the Society for Simulation in Healthcare about Simulated Patients (SP).

The article, whilst interesting and enlightening, discusses the work of the ‘normal’ SP, and shows how valuable their contribution is to medical education. However the title sums up the fact that an SP is more than just an actor who learns their lines and portrays a character. Any role player will be quick to alert you to the fact that, unlike actors, the SP has to give feedback on the communications skills of the student clinician. This is beyond what we expect an actor to be capable of doing.

A good SP can improvise around a common theme, for example breaking bad news. However each student will approach this in a variety of different ways and this is based on their communication style. Some may be hesitant to break the bad news, whilst others may be more exp-licit with their communication. It is the job of the SP to respond to the different approaches that students have effectively, and then give feedback on what the student did well and how they can improve their communication for the benefit of the ‘patient’.

Some students will build rapport readily and easily whilst others need feedback on how to do this more effectively. Non-verbal language also plays its part in communication as we have discussed in a previous post. However, if the SP is presenting with a specific physical condition i.e. central chest pains, the student will respond by performing an examination, for example ‘cardio-vascular’. An SP is unable to give feedback on this part of the process. This is where to Associate Clinical Educator (ACE™) excels.

What the article previously mentioned didn’t cover (and I wouldn’t expect it to) was how an ACE™ can take the interaction to the next level.

An ACE™ is not a Simulated Patient, he’s a simulated patient on steroids! On many occasions I have spoken to clinicians who mistake what we do for medical roleplay and/or that we are simply simulated patients. This is simply not the case.

An ACE™, whilst giving feedback on the communication, will also be able to quickly inform the student whether of not the examination itself is being performed correctly. For example, below is a typical respiratory examination as expected to be performed by a first year physician associate student:

    • Introduction using full name and role
    • Confirms patient’s full name and DOB
    • Explains examination and takes informed consent for examination.
    • Asks if they want a chaperone
    • Washes/disinfects hands
    • Exposes patient appropriately and maintains dignity
    • Inspects the patient’s chest (looking for scars, asymmetry, both axillary area)
    • Positions patient on the couch at 45 degree angle and asks if they have any pain anywhere
    • Inspects the patient’s hands looking for peripheral cyanosis, clubbing, tar staining, CO2 flap
    • Checks patient’s pulse (radial/brachial) checks for rate (90 bpm), rhythm and character
    • Counts respiratory rate (offers to do for one minute: 18/min)
    • Checks patients face for pursed lip breathing, central cyanosis, pale conjunctiva etc.
    • Palpates patient’s chest checking for chest expansion and apex beat
    • Percusses the chest (top middle bottom, axillar, compares left and right)
    • Auscultates the chest (top middle and bottom and both axillar)
    • Checks tactile vocal fremitus or vocal resonance
    • Checks for sacral oedema, feet and legs (for swelling and tenderness)
    • Checks for lymphadenopathy (supraclavicular, cervical, submandibular, etc) from behind
    • Concludes examination, offers to help patient dress
    • Summarises findings in a logical systematic manner (including important negatives)
    • Gives differential diagnosis

Senior Associate Clinical Educator teaching session at Wolverhampton universityThe role of the ACE™ therefore is to give feedback on all of the above. This will ensure that the student performs the examination correctly,to the standard of the current OSCE curriculum and demonstrates safe practice. As you can see the function of the ACE™ far exceeds that of a simulated patient or role player.

This level of expertise requires training and a high degree of commitment from the ACE™ and with that in mind, Meducate Academy continues to train and support new and experienced ACEs whilst they work with us. Alongside that, the various institutions and academics we work with will continue guide and assist us in producing the best outcomes for their students. Vitally important when you consider the role OSCEs play in the students development and assessment.

Training is ongoing and we are still in negotiation with academic institutions to ratify our position in the industry through a strict accreditation process. This will ensure that the quality of our ACEs is of the highest standard and meets the requirements of any academic institution.

 

If you are a Clinical Educator and would like to take advantage of using ACEs as part of your clinical teaching, book now for a free consultation. Contact us via the form below or even give us a call on 07870611850. Thanks again for reading this post.

Working With New Associate Clinical Educators At Chester University

Associate Clinical Educators Vikki, Bob, Howard and Gregg at Chester University
Associate Clinical Educators Vikki, Bob, Howard and Gregg at Chester University

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.

Happy group of Physician Associates at Chester University
Working with this happy group of Physician Associates at Chester University is always rewarding

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!

Sign up here to join The ACE Online Conference 2021

Meducate Academy ACE Recruitment & Training Programme

Meducate Academy ACE recruitment and training programme online

Meducate Academy recently embarked upon a continuing ACE recruitment and training programme with candidates who had expressed an interest in our ACE training schedules. We emphasised that the role we play is vital in ensuring a clinician is safe to practice with an actual patient and how much commitment is required to fulfill the role of an ACE.

Saturday 15th May 2021 was a very busy day at ‘Meducate Towers’ as we embarked upon our continuing ACE recruitment and training programme. After an initial online webinar a few weeks ago we set Saturday as the date to bring in those candidates who had expressed an interest in our ACE training schedules.

After an initial conversation, in which Mark and I outlined our background and history, we then went on to explain the role of the ACE in medical training. We went onto describe the body systems and how the student clinician would examine a patient. What then followed was a typical ACE hands-on session, with Mark playing the Physician Associate Student, and I as the ACE/simulated patient giving feedback.

This was a great opportunity for the candidates to see how much knowledge is required in order for them to fulfill their role with Meducate Academy. I think it surprised those watching just how much skill and knowledge is necessary to perform the task. Though we did explain that we have been in the role for twelve years, emphasising that this was not our expectation of them at the moment. ACE Training is an ongoing process and even Mark and I are still learning and developing our roles as ACEs.

As you can see from the heavily edited video above, Mark was playing a poorly prepared student. This was an extreme example which gave us the opportunity to show how the ACE needs to be alert when working in a situation with a below standard student.

We explained that the student does not expect us to give feedback on the students’ medical knowledge, or on their diagnosis, but on their technique when performing the examination. Of course, we would also comment on the students’ communication skills if we had any concerns.

Our role is to ensure that the student is safe to practice with a real patient and make a valuable contribution to their profession.

After the demonstration was over, we then went into an Q & A session, which included questions on the duration of training and how their assessment will be carried out. We explained that although the initial training is quite short, we will expect them to shadow an experienced ACE until we feel they are ready to take on the role. We emphasised that the part we play is vital in ensuring a clinician is safe to practice with an actual patient, and so stress was placed on the role and how much commitment is required to fulfill the role of an ACE.

Our customers are highly skilled professional educators and we expect the same high standard from our ACEs.

We are currently working on educational materials for the ACEs, and this is being done in conjunction with senior clinicians who are overseeing the development of this information. These instructional materials include training videos, handbooks and regular telephone or internet support along the way.

Meducate Academy has also been working recently with PAs at Wolverhampton and Chester Universities, and we received welcome news that many of our students had passed their National exams. Good news indeed.

Last weekend Mark and I worked with Matrix Education, again helping student Physician Associates get ready for their upcoming exams. It was great to touch base with students from every part of the UK and a pleasure to work with the team at Matrix, as always. I recently did a podcast with founder of Matrix Education Sofia Hiramatsu and we will be posting a video of the podcast next week on this blog.

I have also spent some time with Wolverhampton University developing their Golden 2 sessions on a weekday evening. If you have ever taken part in OSCEs, you’ll know that one of the vital parts of an OSCE station is the 2 minutes that the students have to read the question.

Sometimes, students find this really difficult and often miss the obvious. With this in mind, Peter Gorman of the Wolverhampton PA Program has put together sessions based purely on “how to read the question”. His approach has been really successful. Helping the student get to grips with being able to answer the question effectively, and I can’t believe someone has not attempted this before. Maybe they have!

It has been an honour to be involved in these sessions and I have seen this approach help struggling students turn a corner in their development. I intend to write something with Pete about this in the next few weeks.

The month ahead looks busy, so I would like to thank all those who attended the Webinar on Saturday. We are currently putting dates together for the initial 2 day training course.

If you are a role player who wishes to take your medical roleplay to the next level, we are always on the lookout for new people, so get in touch.

From Comedy to Clinical Education: My Journey As An Associate Clinical Educator

Clinical Director James Ennis demonstrates an Elbow exam with ACE Mark Reynolds
Clinical Director James Ennis going through an Elbow exam with ACE Mark Reynolds

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.

Associate Clinical Educators Bob Spour, Greg Hobbes, Mark Reynolds at The University of Chester
Working with Clinical Director James Ennis, and ACEs Greg Hobbes and Mark Reynolds at The University of Chester

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.

University of Chester. Riverside Campus
University of Chester, Riverside Campus

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.

The Importance Of Feedback From The Physician Associate Student

Meducate Academy - Teaching physician associates the importance of having a systematic approach to physical exams

In my last post The Associated Clinical Educators Role In Providing Feedback To Student Clinicians, I talked about the importance of feedback to the Physician Associate student and how an ACE structures their feedback to ensure that they achieve the best learning outcomes.

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.

Meducate Academy review on Instagram

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.

Primary care for physician associates by matrix educationOn 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.

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.

In Conversation With Senior Associate Clinical Educator Mark Reynolds

Interview with Associate Clinical Educator Mark Reynolds
Associate Clinical Educator Mark Reynolds giving feedback to a PA student on a recent course

A few subscribers have asked me to expand further on the role of the ACE, and this is a transcript of an interview I did with fellow ACE Mark Reynolds a few years ago. It still has relevance today and should answer any questions I have received over the past few months.

Meducate: What can you tell me about the difference between a Role Player and an ACE (Associate Clinical Educator)?

Mark: A role player is involved in clinical communication, in that they play opposite a medical student as a patient or colleague in order to to improve their learning in terms of their technique of clinical communication.  The associate clinical educator is also trained as a role player but is also trained in the body system examination so they are a hand on resource for the student to work on. The ACE then feeds back how well the student carries out that examination.

Meducate: You mentioned the term “body systems” what do you mean by that?

Mark: The basic body systems, from the point of view of the  medical world, would be  the cardiovascular, respiratory, gastrointestinal, neurological and musculoskeletal systems. We are trained to give feedback on their examination technique. Techniques such as percussion, auscultation and palpation.  We  never teach pathology, that’s up to an academic tutor who normally works alongside us.

Meducate: So the academic tutor teaches the pathologies and the theory, and you are the resource? A bit like a living mannequin?

Mark: Yes, we are a living resource able to give feedback on the technique as well as our extensive knowledge of the OSCEs and what is required in those academic exams. At first Techniques like Percussion and Palpation are often a problem for new students, and we can guide them in the correct technique as well as ensuring they’re in the correct position on the body.

Meducate: And because you’re also a communications expert, you can give feedback on their ability to communicate effectively and build rapport with the patient.

Mark: Absolutely yes. Communication is a vital part of the examination process and it would be remiss of me to allow a student to carry on if they couldn’t build rapport with the patient.

Meducate: So can you describe a typical session with an ACE?

Mark: So normally a body system is picked for the day and the ACE will be working with four to six students. Sometimes the clinician may do a live demonstration using the ACE as the model, and then the students will be taken through the various pathologies they may come across on a typical patient. The students would then be left to work with the ACE, and they would then give feedback about how well they are doing. Having a “Talk the Walk” approach works very well, as we can direct the student toward the correct method right from the start. Sometimes we may run a scenario alongside the physical examination and thereby making it more realistic. With the help of the clinician present, we will also include a management plan and how to explain that to the patient in layman’s terms. We can also present various pathologies to the student such as asymmetrical breathing, antalgic gait, Shortness of breath and many more. We even have a member of the team who can create ulcers, bruising, and other physical signs using moulage.

Meducate: I have heard students say that they feel more relaxed when working with an ACE can you expand on that?

Mark: Yes, when a student has a clinician in the room they feel that they are being judged. Which of course is true. We are there as a resource, a tool, if you will to help them develop without judgement. It is true that we assess them, but not professionally. We are not qualified Medics!

 Meducate: ACEs are often used in OSCEs to great effect. How does that work?

Mark: During an OSCE it is not possible for the examiner to feel what is going on such as palpation, and that’s where we can give our feedback about how well the palpation went. Whether it was painful or too light. Because of our intensive hands on training, we know what a good technique is. This ensures that the PA is safe to practice once qualified. It should be remembered too that we have probably been involved in thousands of OSCEs, so we have an extensive experience, often much more than the examiners themselves. Examiners often remark on how extensive our knowledge is!

Meducate: Better than a real patient?

Mark: Yes, very different. A patient will not be qualified to give feedback. Of course, working with real patients is also valuable to the learning process.

Meducate: Thanks for taking time out to chat with us, Mark.