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.
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.
Matt Chapman is Managing Director of Meducate and is a founding member of the company. In this post, Matt talks about his vision for the company and how Meducate differs from other companies he has worked for over the years.
“I’ve been involved with Meducate from it’s inception over 2 years ago and the big thing that stood out for me was how engaged the students were with the ACEs and the methods we use. Feedback was always phenomenal something I hadn’t experienced in any other business before. There’s always a grumpy customer that you have to deal with in any business, but with Meducate it was always positive feedback.
“Every time we engage with an institution and their students, they give us 5 stars across the board.
“When we first met and you talked about the concept of Meducate you were already doing corporate training with me and when you told me about the potential of the ACE role in medical training, I suspended my judgement on how good you said the work was. I remember coming on the first session with one of our earliest customers at Wolverhampton and it was all true. Not only were you and the other ACE enjoying the day but so were the students. Id never seen that level of engagement with anyone in business before. 100% of the class were involved and craved more! That is when I knew we could make this work. In business we always want a win-win situation, and this seemed to be the right type of service to offer. That and the fact that we are almost the only people to be offering this service.
“The fact that this had never been picked up on before and was an open market surprised me. I know there are lots of role play companies out there offering medical role players, but the role of the ACE is unknown. My only concern was, would we have enough ACEs to cover the 40 + institutions that may need our services. Our answer came with the pandemic. This gave us time to regroup and begin training role players in the skills required for them to perform as an ACE. We did this with the help of some senior academic tutors and experienced clinicians who work in the health care sector. Again, this was another of Meducate’s strengths. Our ability to contact the right people is paramount and we are even in discussions to validate the role of the ACE with two Universities keen to promote what we do.
“I was asked recently what drives me in business and I remember we were talking about values and how you see the work we do at Meducate. One of the core values I have always had was with having the ability to measure and monitor every aspect of the customer experience. That would be at all levels. So how well do we handle incoming calls and meetings with potential clients? Feedback from students is something I have already talked about, but what do the clinicians think? How do they feel about utilising ACEs in the educational process and how valuable are they? The answers coming back so far have been outstanding. I really believe in giving the customer what they want and will always work with them to achieve their goals.
“I have always believed in being transparent with the people who work for us and the customer. Keeping everyone in the loop on a regular basis makes for a happy and fruitful relationship.
“What has been difficult, but I have now adapted too, is the sudden changes a client might make at the last minute about the type of training they want delivered? I was surprised by how flexible our ACEs were. They were able to shift gear quickly and improvise, effectively delivering exactly what the customer wanted. This I believe is one of Meducate’s great strengths and is due to the intensity, passion and abilities of the people we have working with us.
“With regard to the abilities of the ACEs I would like to mention that we update the ACEs skill sets every 6 months and will run regular training days to help the ACE with any areas in which they might feel weak. We want everyone to feel like they’re part of a family and if we all look after each other, we will all prosper. It’s a continuing process that we can’t let slip. As times change, we must change, as we have all recently experienced, and we were quickly working online in March of this year. I don’t believe any other organisation reacted that quickly. We were already prepared to provide online trainings anyway, so it was simply a matter of contacting our customers and setting it up.
“In closing, I would just like to say that I feel we are a very under-used resource, but we have professional credibility with several universities using us and several ACEs with over 12 years’ experience. If you want to test us out, why not call us or email or call us for a 5 minute conversation?”