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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.

My Top 10 Tips For Failing The OSCEs

Image of long haired and unshaven medical student
Here are my top ten tips that will assure you fail the OSCEs

The idea for this post developed over the past ten years of my involvement in the training of Physician Associates, Medics, Pharmacists, Dentists and other health professionals. Ten years of working as an ACE and role-player observing those same students pass and fail their OSCEs every year.

I have also spent ten years mentoring and coaching students from all walks of life, at various levels of their education in order to help them become a success.

I have consequently developed strategies and models to help students become safe and competent health professionals. I have seen how successful many of them have become, time and time again.

Over that time, I have also made a careful study of underachievement. The students who fail. I have therefore reached a shocking conclusion that many of the students who fail, share the same strategies on a daily basis that leads to a state of total and absolute failure.

It takes an awful lot of work to fail this well. Often a lot more work than it takes to succeed.

Successful people always reveal that they never feel that they are working for a living.

They’re invariably optimists.

Failures are invariably pessimists.

They usually hate their work.

I have learned a lot from failures.

Failure is a choice… It takes conscious effort!

As I have said, I have studied success too and I know those strategies well. I guess if you know specific strategies for success and do the exact opposite, you’re well on your way to being a spectacular failure.

So, here are my top tips, my step-by-step approach to help you fail the OSCEs majestically.

Of course you could also do the exact opposite… But that would be crazy!!

So here we go:

STEP ONE

If you want to ensure that you fail the OSCE then you must definitely never ever think about what success could mean for you. Avoid, at all costs, positive role models and avoid successful people.

Never define your goals or find your purpose.

STEP TWO

DO NOT turn up early or even on time for lectures. In fact make sure you miss as many as possible. Forget to set your alarm and enjoy those extra minutes in your lovely warm bed. You deserve it after all. It’s been a tough week!

STEP THREE

If you insist on revising, remember to never revise in a structured way. Never plan you day around your study time.There are more important things to do. Tidying up your room, washing the dishes, the laundry or catching up on the a Netflix series that you missed first time around.

STEP FOUR

As the OSCE dates get closer never try to be optimistic about this approaching nightmare. Do anything but think about those exams.

Reaffirm on an hourly basis, that it’s going to be difficult. Maybe even impossible. OSCEs are difficult and scary.

STEP FIVE

Repeat Step Four the night before the OSCE and stay up late. Never get an early night and always panic. Lots of panicking!

“DO NOT REMAIN CALM.”

STEP SIX

You have somehow made it to the OSCEs and you are at your first station. Whatever you do… DO NOT READ THE QUESTION PROPERLY! Tell yourself that those two minutes are going to fly by, so only give it a quick scan.

STEP SEVEN

Never tidy up your appearance. Do not iron your clothes and always wear something inappropriate. You washed your hands earlier in the day, so do not use the hand gel when you enter the room.

STEP EIGHT

When you enter the room, lack confidence. This shouldn’t be difficult if you have followed the previous seven steps. If you look scared, you may win a sympathy vote. Mumble your name incomprehensibly and as fast as you can to save time.

STEP NINE

Forget to take notes. If you have been stupid enough to have wasted time making some outside the station… NEVER refer to them again. Remember to leave your stethoscope and watch at home. You can borrow them from the examiner, anyway!

STEP TEN

Have no structure when performing a systems exam. You’re a free spirit and want to show your improvisational skills to the examiner. When taking a history, DO NOT make eye contact. DO NOT listen for cues and always use jargon. Keep saying: “OK. OK. OK.”

Finally. Thanks for coming this far with the article. You have succeeded at something! Best that you forget everything I have said and now delete all the above from your memory. That would just take up valuable space.

This is by no means a complete guide for failing the OSCEs. That would take a book and you probably wouldn’t be bothered to read it, anyway. Avoid books, research papers and journals related to medicine. Hello magazine has more pictures in it, is more interesting and wastes a bit of time.

Meducate Academy Educating The Next Generation Of PAs

ACE Mark Reynolds roleplaying with a 1st Year PA student at The University of Chester
Meducate ACE Mark Reynolds roleplaying with a 1st Year PA student at The University of Chester 1st Year OSCE

Meducate Academy has had a busy two weeks working alongside the University of Chester, University of Wolverhampton and Matrix Education on several exciting projects.

As always, Matrix Education delivered an excellent two day course, this time in a beautiful hotel deep in the heart of London’s West End. We were there in our capacity as Role Players and Associate Clinical Educators providing our role play and lay clinical education services to the PA students about to take their National Exams. Students from Bournemouth, Reading, Sheffield, Birmingham and other parts of the UK were in attendance.

We encouraged the students to stay engaged with both history taking in the morning session and physical examinations in the afternoon. We also coached them in techniques that would allow them to get through the exams with confidence and advice on how to lower their stress levels prior to the OSCE.

Associated Clinical Educator Mark ReynoldsOnce the weekend was over we were booked to work with 2nd year PAs at the Riverside Campus at the University of Chester. They tasked us with delivering a whole range of skills. We went through all the systems exams from Musculo-skeletal, through Cardiovascular examinations and some challenging scenarios thrown in. One of our team also ran a breast examination station, giving the students an opportunity to practice important but often neglected skills, including feedback on their technique from the associate clinical educator.

After two days of teaching in Chester we were back on the road the next day day to Wolverhampton University, working on an OSCE with my old colleague and the developer of the ACE role, Professor Jim Parle and the PA Course Clinical Lead Pete Gorman.  Despite the obvious restrictions placed on us due to Covid-19, we were still able to perform at a high level.

Meducate were represented by two roleplayers on the day and the feedback was excellent.

This week has seen us travelling back up to Chester for a mock OSCE with 1st year PAs. We were tasked with providing two ACEs and also with the filming of one of the history stations. This presented us with its own challenges. We are fortunate in having some new cameras, lights and sound equipment, which proved their worth on the day. The quality of the video was excellent and Chester are thinking of using this set up as a regular feature of their training programme. It is a great way for students to check on their own progress and has the added bonus of being available for them to access during their revision.

It is great to get back to working with students once more, and for many the Covid-19 crisis has been problematic.

At Meducate Academy we used this time to create opportunities and we are glad to say that we have been having our most successful year yet.

I also spent some time chatting to one of our most senior ACEs and role players Mark Reynolds, and he offered to pen a few words about how much he enjoys his role working with Meducate Academy.

Mark has been involved in Medical Role Play and ACE work for over twelve years and he is also a great facilitator.

“I have been pleased to be part of the Meducate team since day one and hope that my input in those early days helped the company to shape the way forward.

Meducate is really up and running now and we are currently enjoying working for the Universities of Chester and Wolverhampton on their Physician Associate Programmes, as well as working on pre-national PA OSCE courses for Matrix Education.

ACE Mark Reynolds
Mark Reynolds

The role of the Associate Clinical Educator is something I have been identified with since 2008. My background in performance helped me to become an effective educator and I enjoy so much teaching clinical communication skills and body system examinations. I believe that it is very important in life to seek a role that makes a difference. I can see when my colleagues and I are working with PA students that we are making a difference to their learning; helping them to improve their communication and examination skills and most importantly, helping them to reach that point where they pass their formative and summative OSCEs.

I’m proud to be an ACE, indeed I’m one of the longest serving ones in the UK, and it’s a lot of fun working with these students and my colleagues too. When you’re having fun and being paid, life doesn’t get any better than that.”

Mark Reynolds

RECRUITMENT OPPORTUNITIES

If you are an Actor / Roleplayer who wishes to train as an Associate Clinical educator please get in touch with Matthew Chapman at Meducate Academy. We will be offering Free Training Courses in the coming months, to help you realise this ambition.