Communication Skills

Mastering The Skill of Listening: A Key To Patient-Centred Care

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Image showing Meducate Academy teaching consultation skills to a group of pharmacists during their Clinical Pharmaceutical Team Meeting.
Meducate Academy Teaching Consultation Skills to Pharmacists at their Clinical Pharmaceutical Team Meeting

In this article, we explore the role of ACEs in healthcare education and the importance of effective communication skills. We discuss the impact of active listening on building rapport with patients and avoiding miscommunication. Drawing insights from experienced pharmacists, we address the challenges of difficult conversations in healthcare. We also highlight the wisdom of Plutarch and the practicality of Anatol Rapoport’s rules for navigating such conversations. By emphasizing the collaborative nature of communication and its life-saving potential, we stress the significance of effective listening skills. ACEs and healthcare professionals are encouraged to prioritize listening as a foundational skill and utilize tools like the Rappoport Rules for improved communication.

Image of Agenda of Pharmaceutical Team Meeting at Dudley College of Technology
Pharmaceutical Team Meeting at Dudley College of Technology Agenda featuring Meducate Academy

How often do you hear what someone is saying but fail to truly listen? How frequently do you find yourself waiting for the person to finish speaking so that you can assert your own thoughts, often with a prepared speech centered around your own agenda, without genuinely addressing the original question? These are the subjects I intend to explore in my writing this month.

As ACEs (Associate Clinical Educators), it is necessary and important that we provide accurate feedback on students’ technical competencies. The feedback should, of course, be relevant and precise, enabling the students to develop as safe practitioners. Another essential aspect of our role is to assist students in developing effective communication tools to establish rapport and gain the trust of simulated patients. This becomes particularly relevant when students embark on their journey to master the art of effective history-taking, marking their initial exploration of the realm of effective communication.

I always emphasize to students that the essence of communication lies in the response one receives. This is crucial because failing to genuinely listen to the patient can result in miscommunication. Each party brings their own agenda to the conversation – the clinician and the patient have their respective goals. It is no wonder that communication can be seen as something of a dark art. Therefore, the role of the ACE is to carefully guide the students through the process.

Always remember that a conversation is a partnership. It is a collaborative process, led by the patients’ ideas, concerns, and expectations, with the clinician and the patient working together.

This topic emerged during a recent Clinical Pharmaceutical Team Meeting held at Dudley College, where my colleague Mark Reynolds and I were invited to speak about Enhancing Consultation Skills to a group of highly experienced Pharmacists. In addition to discussing generic communication skills, we presented a couple of scenarios illustrating poor and effective communication and engaged in discussions on the points raised.

One of the key themes that emerged from the pharmacists was the common problem of patients demanding specific drugs, such as antibiotics, and how to handle such situations. Another recurrent theme was the instances of angry patients being informed about the cost of prescriptions. In other words, the main focus of the discussion revolved around managing difficult conversations.

Effectively navigating a difficult conversation requires active listening, and most of the attendees were eager to hear our thoughts on this matter. Like any skill, it demands constant practice and simply paying attention to the conversation. However, finding the time to listen is challenging in today’s busy pharmacy or GP surgery, where restrictions are imposed on the duration of patient interactions. Nonetheless, learning this skill is vital.

In order to build rapport and gather important information, we allow the patient to talk and express their needs. This is of utmost importance.

Greek philosopher Plutarch, Greek philosopher philosopher, writer, magistrate and priest
Plutarch, Greek philosopher, writer, magistrate, and priest who lived during AD 46, extensively wrote about the subject of listening

Plutarch, the philosopher, writer, magistrate, and priest who lived during AD 46, extensively wrote about the subject of listening. It might be useful to briefly examine his views, as expressed in one of his letters to a young man about to embark on his studies. He discusses different types of listeners: the Lazy Listener, the Scornful Listener, the Excited Listener, and the overly confident listener.

The lazy listener is someone who only listens for information that interests them and shows no interest in what the speaker is saying. They wait for their turn to expand on their own interests, paying little attention to the speaker’s main topic of conversation. The scornful listener is judgmental of alternative ideas or beliefs, as they adhere strictly to their own set of values and beliefs. Plutarch notes that judgment is, in fact, a distraction of the mind, and these types of listeners tend to develop a distorted view of what is actually being said. It is better to have an open mind, he says – a sentiment with which I wholeheartedly agree. We must not let the speaker’s performance distract us from paying attention. Otherwise, we will quickly forget our purpose and potentially miss valuable information. Finally, Plutarch talks about the Overconfident Listener, who assumes they know what the speaker means right from the start and fails to listen for subtle, sometimes hidden, cues in the conversation. When this happens, it is important to step back and actively listen.

Even Plutarch recognized that a conversation is a collaborative process. The responsibility for the outcome of a conversation rests with the listener and with healthcare professionals. Achieving the correct outcome is crucial, and listening can literally save lives.

Throughout my experience as an actor, comedian, corporate trainer, NLP trainer, and associate clinical educator, I have employed various methods to teach communication skills to students in different fields of study. From armed response teams to salespeople, from actors to presenters, and more recently to physician associates, pharmacists, nurses, and young doctors, the process remains the same: learning to listen first and foremost.

At the recent Team Meeting in Dudley, I extensively discussed the use of Rapoport Rules as a valuable tool for communication skills. I encountered these rules a few years ago and have always wondered why they are not more widely known. Anatol Rapoport, a Russian-born American game theorist, developed a set of rules for handling difficult conversations:

  • Clearly re-express your conversation partner’s position, defining your understanding of what they want. This ensures clarity in the conversation and prevents you from straying off course with your own assumptions.
  • List points of agreement with your partner to develop rapport further.
  • Always mention something you have learned from the person you are talking with, further building agreement.
  • Only then can you proceed to disagree or compromise with the person. You can see how these rules can be helpful when patients hold fixed beliefs about vaccines, antibiotic use, or various other treatment-related ideas.

I encourage you to follow and practice these steps each time you engage in a difficult conversation. If you are an ACE, please be aware of these tools and pass these skills on to students during their history-taking sessions. The positive impact will be appreciated by everyone.

Next month, I will be talking about our work with Newcastle University PA program teaching musculoskeletal (MSK) examinations.

 

If you’re a Pharmacy Clinical Lead and wish to discuss working with Meducate Academy Ltd., we would love to give you a demonstration and a workshop at your institution.

Please contact: bobspour@meducateacademy.com or on 07870 611850

15 Questions to Test Your Skills as an Associate Clinical Educator

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Meduucate Academy ACEs with Medical students at the University of Chester
If you’re an Associate Clinical Educator (ACE), you may have wondered what sets you apart from a simulated patient or medical role player. In this article, we will be exploring this question and providing a useful questionnaire that will help you become a better ACE, teacher, and communicator. Our goal is to improve the quality of ACEs by answering important questions and providing helpful training resources.

How well do you really know your role as an Associate Clinical Educator? I have been thinking for a while now about creating a quiz for ACEs. I wanted to find out what makes an ACE more than just a simulated patient or medical role player. I believe the following questionnaire will help us become better Associate Clinical Educators, as well as better teachers and communicators.

Over the past couple of years, Meducate Academy has been putting together training courses to help existing ACEs and simulated patients improve their existing skills and introduce new people to the role of the ACE. We are always striving to improve the quality of our ACEs, and in order to do that, we always listen to what they have to say.

When I was starting out, many of these questions were never answered satisfactorily, and after much discussion with our existing ACEs, they all seemed to ask the same questions.

On the 13th of this month (May 2023), we will be running another one-day training course aimed at potential ACE. These are normally people who have been medical role players or have some experience as simulated patients and wish to take it to the next level.

If you are one of those people, you might find it helpful to ask yourself these questions below. If you are an experienced ACE, you could revisit this questionnaire or add more questions to the list.  So, get a sheet of paper and answer these questions now.

1. When did you first start working as a medical role player and why?
2. When did you start working as an ACE, and how easy was the transition?
3. How often do you work as a medical role player or ACE?
4. What types of students have you worked with, and did their needs differ?
5. Have you been involved in OSCEs or any other type of examination?
6. Was the training we gave you adequate, or do you feel it was confusing?
7. What type of training would you find most useful?
8. Which aspect of your previous training (prior to medical roleplay/simulated patient/ACE) has helped you engage with your current role?
9. Where do you find resources that help with your current role?
10. What new resources would you find useful to help you improve the quality of teaching?
11. How much do you think your personality affects the learning outcome, and do you think you should spend more time on that aspect of your training?
12. Do you know how to teach a student how to develop rapport with a difficult patient?
13. What do you get, at a personal level, from teaching as an ACE?
14. How do you structure feedback to the student?
15. Do you always achieve your desired outcome when teaching, and if not, do you reflect on what you could do better next time?

We came up with these initial 15 questions, but we welcome any suggestions. As we ask these types of questions to our new ACEs, it’s essential to understand that none of us are experts or masters of our craft.  Acknowledging that there is always room to learn something new helps us stay vigilant. Our honesty fosters implicit trust from our students, and they feel that we are with them on their journey.

The type of people we are looking for are those who say, “C’mon chaps, let’s get stuck in,” not “Go on, chaps, off you go.” Lead from the front. We are there to work with the students, not talk at them. Build rapport with the students, have the flexibility to change your behaviour when you need to, be aware, and you and the students will achieve their desired outcomes.

Have an open mind and question everything! At the end of the day, that is what education should be about. That is how we grow and become better humans.

If you are interested in joining us or want to have a chat about our one-day training course aimed at potential ACEs on 13th May 2023 get in touch. Please contact: bobspour@meducateacademy.com or on 07870 611850

 

Bootcamp For Physician Associate Students At Chester University

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The Meducate Team and some 2nd year PA students on their Bootcamp at The University of Chester

The Bootcamp for Physician Associate students at Chester University is an intensive training program designed to help students prepare for National Exams. It involves practising skills, receiving feedback from experienced trainers, and honing communication and consultation skills. The Bootcamp is structured over three days and covers a variety of conditions and scenarios, including multi-systems examinations. The program is designed to help students deal with stress and pressure in a simulated exam setting, and to conform to the standards required by OSCE assessors. The Bootcamp ends with the students having the opportunity to practice under exam conditions and receive feedback.

Who Dares Trains!

Putting the Physician Associate student through their paces.

I think it is essential to define what I mean by Bootcamp. The definition of a boot camp is an intensive way to obtain knowledge about a specialisation. In the case of the Physician Associate program, these are related to medicine.

A common practice is to take the students (usually 2nd years) through a whole range of skills working with ACEs, mannequins and clinicians to help them hone their skills and then receive focused feedback at the end of the process.

The idea of the Bootcamp comes from the military where soldiers are put under intense pressure and made to perform the skills they have learnt in their area of expertise. Unlike the military, we do not shout at students but guide them with structured feedback. They do feel pressured to perform which helps them deal with the stress of their upcoming OSCEs. This is also a valuable skill for a PA as they will inevitably find themselves outside of their comfort zone when out in the workplace. In particular Emergency Medicine and Breaking Bad news.

Bob works with students on the intensive bootcamp held at the University of ChesterThe ACE plays a very important part in this process, and because of their high level of knowledge and skill can replicate the patient journey in fine detail. This is what distinguishes us from volunteers or role-players, who give high-fidelity feedback on more than just communication skills. An Ace is trained to give feedback on the way a student handled the patient, and the efficacy of the techniques they are using. For example, the way the student auscultates and percusses the patient or the way the student used palpation.

Did the student perform the examination using the accepted methodology? Did they conform to the standards required by the OSCE assessors?

Each institution has its way of running the boot camps, but generally, the structure is something like this:

Day One: Introduction to the methodology and approach expected from the student. Consultation skills: History taking on a variety of conditions to be determined by the academic staff.

Challenging scenarios related to the workplace. It is not just patients that can be a challenge, but colleagues too, so it is important to learn how to have difficult conversations.

Day one usually ends with a group discussion about what they would like to cover over the remaining 2 days. At Chester University, the students worked with 4 experienced ACEs and we covered Cardio, Respiratory and GI. We practised them as stand-alone examinations and blended them, where a patient would present with a pathology that required a multi-systems approach. The students always find this a challenge but usually do well at this level of their training.

We also worked through MSK and Neurological examinations.

For a Physician Associate to prepare for National Exams it is always great for the team at Meducate Academy to get the feedback they deserve. We work hard to ensure the students get the best tuition and feedback.

The two years working with this cohort have flown by, as they say, and it has been a journey filled with surprises and detours. Plain sailing and a few rough patches, but when all is said and done we got there in the end!

PA Students sent a thank you letter to Meducate Academy teamBoot camps are a great way to help the students tie up any loose ends they may feel they have in their understanding, and I am pleased to say we and the academics were there to support them.

I got the sense that the students were more than ready for the nationals and we wish them all the luck for their future as Physician Associates.

As an aside, it was also great to get a ‘thank you’ card from the students, which was totally unexpected but very welcome. I look forward to being at their graduation.

So, it is onwards and upwards for the coming year and 2023 promises to be a good one with us working closely with our partners and also with Pharmacists at Wolverhampton University.

If you’re a Clinical Lead or Senior Lecturer and want to have a chat with us about how we can add value to what you already get in touch. We would love to give you a demonstration and a workshop at your institution. Please contact: bobspour@meducateacademy.com or on 07870 611850

 

Building Rapport and Maintaining Empathy In Challenging Scenarios

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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.

Diversity & Confidence Building In Medical Simulation

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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!

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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.

James Ennis On The Use of ACEs & Roleplayers In Clinical Education

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James Ennis Clinical Lead at The University of Chester Physician Associate Programme

James Ennis is currently Clinical Lead at The University of Chester Physician Associate Programme. He has worked with ACEs both as student Physician Associate, and also used ACEs when he was teaching at The University of Birmingham and latterly at Chester University. Here we have an overview of his contribution to the Meducate Academy ACE Online Conference 2021 in an abridged form. If this sparks your interest please watch the attached video and share the link with colleagues and friends.

“Today on the conference, I’m just going to quickly give you an overview of how we use Associate Clinical Educators at Chester University. This was quite a new concept to Chester and as I’ve recently moved from Birmingham up to the area, I decided to bring the Associate Clinical Educator role up with me. We consider the ACEs to be an integral part of the teaching team, and so I’m now going to talk about how we use them and where we use them. I’m going to give you some quotes from our students about their experience in working with ACEs on the course and more importantly a little about simulation and the ACEs themselves.

“I’d like to give you a balanced opinion on the role because there are some perceived threats, in my opinion about the use of ACEs and roleplayers. I want to talk about the future development too at some point. The main point that should come across is that the ACE can give accurate Hi-Fidelity feedback to both the teacher about the student and more importantly to the student themselves.

“Typically a roleplayer is used as a live patient often able to give feedback to the student in terms of their communication skills. The ACE does this and more. They can give  feedback on the physical examination skills themselves, both from the point of view of safety and technique. We’ve kind of gone away from the compartmentalisation of history taking and then  physical examination skills and we have looked at it more as a kind of an integrated model which is how clinicians truly consult. As well as that, we use the ACEs in specialist roles for example intimate examinations.

“We also use the all singing all dancing SIM Man. This is what we would typically think of with regard to high fidelity simulation. Of course we do use the Sim Men as well, particularly for emergency scenarios, but we also use the ACEs as part of a role play that would fit into the scenario and so the communication isn’t lost during the interaction.

“During the pandemic we also had to change the way we worked with ACEs and a lot of the work was carried out online. This also fitted in with the growth of online consultations that are now part of a clinicians responsibility. Of course this is useful for maybe online medication reviews but not for someone presenting with acute abdominal pain.

“To maintain balance of opinion I’ve captured a few of our most recent students/staff liaison minutes from meetings and these  are from our year two students. These are kind of common themes so I’ve just picked a few just to quickly touch on.  Looking at the completely comprehensively positive feedback from from students on the ACEs role and what they give to the student.

“Many students said that they find working with the ACE far less threatening, particularly when making the inevitable mistakes while performing physical examinations, and they were able to refine their technique with the ACE. However, I would like to  mention that it does say that mannequins and other types of simulation may be just as helpful.

“Now, what I would say is, I don’t see the ACE role completely dominating simulation in medical education. It’s very much used as an adjunct and that’s how we now utilise our ACEs. Also  the students obviously get quite twitchy around OSCE season assessment periods. Again, we found the ACE  to be  incredibly helpful, not just for improving students technique and examination skills but also in building their confidence.

“Again, as Professor Jim Parle mentioned previously, the students really responded positively to the ACE role in working on things that they find specifically difficult. One of the things I’d like to highlight is the MSK examinations. It’s one thing that our ACEs really cover in depth with our students. All of our ACEs are heavily trained in MSK examination technique as I’m sure Uzo will talk about in far greater depth in his talk.

“The student feedback has always been positive and more time with ACEs is constantly being requested. This is why we really are so keen on simulation with ACEs.

“I’m sure most of you haven’t used ACEs or simulated patients in any great detail, but you will find that they have had some push back from institutes, mainly because of  the financial burden and restricted budgets. The way we’ve worked around this, is I would far prefer to have the human factor in  simulation than simply by props and Sim Men, sometimes costing up to £80,000. Sim Men have their place, but I would prefer to spend our money towards the use of ACEs. I have  certainly not had any problems from my institute with  getting the financial backing, especially when we keep  getting such excellent feedback.

“We haven’t yet got a great amount of evidence on the  student and patient outcome from such interventions and that’s something I’ll come onto later.

“Another thing, although the ACE is highly trained they are of course not a substitute for a skilled clinician. They are always available to discuss and answer questions of a clinical nature and each supports the other. The ACE and the clinician work as a team.

“So, that’s just a quick overview of where I’m going with my research and I would invite anybody to contact me if they are interested in this subject. I’m constantly monitoring the impact the ACEs have on student performance, and therefore patient outcomes after training. Take a look at the slides I have provided and I am as always interested in any questions you might have.”

Click arrows to view PowerPoint slides of this talk by James Ennis

The Importance Of Simulation In Medical Education

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Professor Jim Parle discusses the use of Associate Clinical Educators at the online conference

Professor Parle was our keynote speaker at the conference and it was an honour to have him join us. What follows is an abridged version of the talk. If you want to view the complete talk it is available in the video above.

“I’ve been involved with the ACE process for something like 15-18 years or so. I am now a retired professor at the University of Birmingham and I’ve been using ACEs and similar kinds of approaches to education for a long time. What I’m going to do today is to go straight into talking about what ACEs are and why we introduced them into the Physician Associate Course and what sparked my interest in education generally.

“We used ACEs on the PA programme for probably at least 15 years if not longer, so for today’s conference I would like to spend more time talking about simulation generally. Also, would like to talk about why we need simulation and why I think we need more simulation and why I think we need high fidelity simulation by which I mean using real human beings, not computers or robots!

“Obviously there’s an ethical issue about performing intimate or any kind of physical examination on actual patients. When I was a student, which is quite a long time ago, we used to examine patients without consent. The patient wasn’t really given an opportunity to say no.

“Obviously you should never do this kind of thing and fortunately, times have changed. I remember my first female patient examination, in which I was embarrassed. She was embarrassed, and I was probably incompetent. I don’t think I hurt the patient, but I didn’t know what I was doing. Looking back now, it was a ridiculous way to learn to carry out examinations. That is one reason we need to think about simulation.

“There’s also the point that medical students need repeated practise and repeated, focused and relevant feedback. You don’t really get that from a patient and when you examine a patient, they rarely know whether you’re doing a good job. We don’t really give them a voice, so we need to have or recruit a patient or patient substitute who is skilled in that area.

“There’s also the issue that students arrive with different levels of skill. You therefore need somebody who can work at the level the student is at. We can’t expect a real patient to do that, as they’ve got their own problems and their own things to focus on when in a consultation. An ACE, however, can do that and more, because we have trained them to be able to show certain kinds of pathology or abnormalities.

“I’ll give you an example: A patient comes off his or her bike and injures their chest. Maybe a couple of fractured ribs and difficulty breathing. If you were to examine an actual patient, they will be in a great deal of pain. They will have tenderness around the area and having restricted breathing. It would be unethical to subject an actual patient to multiple examinations by new students. With an ACE, that problem won’t occur. Some of our ACEs can even demonstrate asymmetric breathing and can obviously be examined throughout the day by many students with no ill effects.

“We can therefore reproduce an extremely convincing simulation with an actual person who the student has to interact with just like an actual patient, but they’re not putting a patient through all that kind of discomfort.

“I just want to add the importance of recognising what is also normal and an ACE can present both sides of this situation. Consider the previous example of asymmetric breathing. The ACE can easily demonstrate what is normal, then quickly change to abnormal. I can only assert that it’s much easier to learn something that’s abnormal when you have something normal to compare it with and, obviously, vice versa. The ACE  can do this. Is able to switch asymmetric breathing too symmetrical breathing and back again so the student can see the difference and we as human beings are good at spotting differences but not so good at spotting absolute values. On a similar but not quite the same theme, I am concerned that if we learn something incorrectly, then it becomes difficult to unlearn it.

“I think it’s really important when students are learning physical examination skills that they compare normal with abnormal there and then. This means that they get immediate feedback, and which they don’t necessarily get with mannequins.

“Because of austerity and the current COVID crisis, students are not able to wander as freely around the wards interacting with patients as they did during my time as a student. So pressure on clinical learning environments and the clinicians who might teach us has become more and more restricted. It’s becoming increasingly difficult for students, whether medical, physician associates or pharmacists, and I’m sure it’s true of other clinical professions that an ACE could fulfill that role.

“An ACE is somebody who’s been trained to use their body and their psyche in educating clinicians by responding appropriately when asked to do something by a student. An ACE, as well as being a responsive patient, can also play a naïve patient, so if simple instructions are not given, the ACE will respond appropriately. If the student wants to take a blood pressure, for example, then the ACE knows exactly how this should be done. An ACE can replicate being a patient who has never had it done and do a variety of things that will affect the blood pressure reading. The ACE can then teach the student how to do it correctly. The student can see the blood pressure go up and down when a patient moves their arm or flexes their muscles. They will see the blood pressure go up and down. The student then gets the reason for doing it correctly and shows that they can do it correctly. This is immediate feedback and students love feedback. They’re always asking for more feedback! If it applies to the individual students’ strengths and weaknesses, they then improve straight away.

“So in conclusion I think I would say that what ACEs bring to the interaction is that they can role play, they can show abnormalities including assessments, they can understand what errors students make or errors patients make and then feedback to the students.

“The most important thing I want you to remember from what I’ve said is it’s sometimes good to take the clinician out of the room when the ACE is working. You do not want a clinician in there. If you have a clinician in with the ACE there, they’ll inevitably get into discussions about various pathologies and what a particular system does in terms of it’s function.

“The ACE is there to work as a tool to aid in the learning of the systems exams. We can do the theory at another session. Making full use of the ACE is vital and students’ feedback always shows they learn the examination processes quicker when the academic leaves the room!”

Click here to watch Professor Jim Parle talking about the value of using ACEs as simulated patients on the ACE National Conference 

Clinical Communication and History Taking – An Associate Clinical Educators Perspective

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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.