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

 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

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 

Meducate Academy’s First National Online ACE Conference

Meducate Academy’s First National Online ACE Conference

Meducate Academy are pleased to announce their First National Online Conference on The role of the Associate Clinical Educator in Medical Education.

As I have said repeatedly, Simulation with an ACE plays a very important role in helping Medical Students, Physician Associates, Pharmacists and other health professionals in the application of their skills. This coupled with the use of other tools such as the Sim Man, anatomical models and volunteer patients integrate the teaching so that the students practical development is maximised. It prepares them to work with real life patients.

More often than not students only get to practice these skills on volunteer patients and mannequins. Neither of these can replace the type of feedback given by a human being in real time.

A few years ago this problem was addressed by Prof Jim Parle at The University of Birmingham on the Physician associate Course. He realised the importance of high quality feedback and created the role of the Associate Clinical Educator (ACE). The ACE, as we have previously said, is a highly experienced medical roleplayer who has been trained by clinicians to understand “how” the Systems examinations should be carried out. The ACE will then guide the student, allowing them to develop their skills in a safe and controlled environment.

It is also important to realise that as well as aiding the student in passing their OSCEs, the ACE role is there to help the student develop safe practice. This is a topic that is often not mentioned and this too will be discussed during the conference.

At the present moment ACEs are only being used by three institutions in the UK.

Birmingham University (In house through the ISU)
Chester University (Meducate Academy)
Wolverhampton University (Meducate Academy)

We are inviting clinical leads as well as those involved in simulation in the health professions to attend free of charge.

You will have a chance to listen to 5 key speakers who currently use ACEs alongside traditional methods of simulation and also get to see a brief example of how an ACE works with a student. This will be followed by a Q & A session with the speakers themselves.

The Line Up:

Professor Jim ParleProfessor Jim Parle

Professor Jim Parle will be speaking about the history of the role of associate clinical educator and his part in its development and what the future holds for simulation.

Jim Parle was Professor of Primary Care and was Course director for the Physician Assistant PGDip programme at The University of Birmingham. Although retired he continues to work tirelessly on a variety of projects.

Jim entered General Practice in 1982 and was Senior Partner from 1983 to 2000, continuing part-time General Practice alongside academia since then.  Jim’s main activity in his 20 years as an academic has been in education, leading on the introduction of a major community based teaching strand within the MBChB course; championing the place of non bio-sciences such as ethics and law and behavioral science in the medical curriculum; establishing the PA PGDip; and leading innovative educational approaches such as using lay women to teach medical students how to perform female pelvic examinations. His research interests have been predominantly in thyroid epidemiology and in education. He has received grants from, among others, the RCGP, PPP (now the Health Foundation) and the NIHR.

Jim had also led the development of community based experience for medical students, initiated (with Dr Sheila Greenfield), the innovative and successful intercalated degree in non-bioscience subjects; led the development of various types of simulation as enjoyable and effective learning methodologies for clinical skills and set up one of the first, and by most measures the most successful, postgraduate diploma in Physician Assistant studies in the UK. He was also chair of the UK and Ireland Board for PA Studies. He has been on the Steering Committee for the Biennial International Clinical Skills Conference series held in Tuscany, and chaired the Scientific Committee for that conference.

He is well known in the fields of thyroid epidemiology and, in education, particularly in the development of innovative approaches to learning clinical skills. He has spoken at numerous conferences on these issues (e.g. quinquennial thyroid conference, Buenos Aires, Ottawa conference on assessment, Toronto).

He recently stepped down as Chief Senior Examiner of the RCP Faculty of Physician Associate National Exam board.

James Ennis Course Director University of ChesterJames Ennis

James has worked in a number of clinical fields across the UK including general surgery, trauma and orthopaedics, acute medicine and general practice. He has worked in educational institutes across England and is currently research active. His research interest is in the PA role in the UK and the use of simulation in medical education. Recent publications include:

Effectiveness of technology-enhanced simulation in teaching digital rectal examination: a systematic review narrative synthesis.

Physician associates: the challenge facing general practice.

Physician associates working in secondary care teams in England: interprofessional implications from a national survey.

James is currently the Course Director of the MSc Physician Associate studies at the University of Chester.

Kate Straughton President FPAKate Straughton

President of the Faculty of Physician Associates and Senior Lecturer at The University of Birmingham Physician Associate Programme.

Kate is a qualified PA, graduating from the University of Birmingham in 2009 and completing her MsC in 2017 from the University of Worcester. She has over ten years experience including working in acute medicine and neurosurgery. She has been working in PA education since 2014, with a focus on work-based learning and clinical placements. Kate is currently the placement lead for the University of Birmingham PA course, and also oversees the MsC ‘top up’ for PAs who wish to carry out some further research.

Uzo Ehiogu Uzo Ehiogu

Uzo is a Clinical Specialist Physiotherapist who led the Spinal Therapy Unit at London Bridge Hospital in London, England. In that role he was responsible for the specialist spinal rehabilitation of post surgical patients referred by orthopaedic, upper limb and neuro surgeons. He also acted a source of clinical expertise for lower quadrant related dysfunction within the department. He now heads up the training of 4th year Medical students in Musculo Skeletal Examinations at the Royal Orthopedic Hospital in Birmingham as well as working in a busy clinical role.

Uzo is a retired British Army Physiotherapy Officer of the Royal Army Medical Corps. He spent several years in the Royal Marines Commandos and qualified as a Parachutist before being selected for a Commission in the Army as an Officer. During his service in the Army he has worked in secondary care, primary care and occupational health environments.

One his most recent appointment was as the Rehabilitation Officer at the Royal Military Academy Sandhurst providing clinical and administrative leadership for a high performance musculoskeletal service. He was the clinical lead responsible for the delivery of a high class service in a premier military training establishment for injured soldiers. He led the  accelerated return to military training and work of patients with career threatening injuries requiring ongoing care and extended rehabilitation for periods of 4-8 months.

Uzo deployed to Afghanistan twice during his Army service years in support of British Special Forces personnel. He conducted specialist musculoskeletal clinics. This role required independent decision making regarding the clinical diagnosis and future management of high value personnel.  He has also worked as a Specialist Physiotherapist at Defence Medical  Rehabilitation Centre Headley Court.

Uzo has worked in the National Health Service as a Senior Physiotherapist where he developed a Pilates and Spinal Stability retraining service in East London England. He has worked for several football teams in Northeast London, England, most notably at West Ham Professional Football Club as the Youth Team Physiotherapist.

Uzo is a Bachelor of Applied Sports Science, and an accredited Strength and Conditioning Specialist with the National Strength and Conditioning Association USA. He is also a Bachelor of Physiotherapy and is in his final year of a Clinical Masters of Science Degree in Manipulative and Manual Physiotherapy. He is a keen researcher and reader and is currently involved in a year long prospective research project investigating lower limb injury risk profiling in British Army Officer Cadets.

Mark Reynolds Mark Reynolds (Host) Mark has been working as an ACE since 2008 having trained as a medical role player two years previously. Aside from teaching cardiovascular, respiratory and gastrointestinal examinations, his special interests in the ACE role include clinical communication, orthopaedic examinations and Mark is a leading educator in the male intimate examinations. Outside of the ACE role Mark is currently involved with various narration projects for the BBC Doctor Who franchise.

We look forward to you joining us on the 4th September 2021 at 12 noon and engage with our experienced clinicians who will talk about their experience of simulation in teaching practice and how the ACE has helped their students develop important clinical and communication skills.

Click here to register for Meducate Academy’s First National Online ACE Conference

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 Physician Associates Program And The Role Of The ACE

Bob Spour working with Clinical Lead Pete Gorman at The University of Wolverhampton
Working alongside Clinical Lead Pete Gorman at The University of Wolverhampton

Congratulations are in order to all of those Physician Associates who were successful in passing their recent National Exams.

The Physician Associates Program is a very intensive 2 year Post-Graduate course and requires great dedication, focus, resilience and determination to complete. It takes many hours of reading, studying and practicing hands on skills training to produce a competent and safe PA.

Image of the University of Wolverhampton from the PA Skills suite
The University of Wolverhampton from the PA Skills suite

Working in close partnership with The University of Chester and The University of Wolverhampton has shown me how demanding the course can be. I see it as my duty as an ACE to ensure that the PA student gets the support and the skills they need to progress in the profession

As an ACE it is also important to keep up to date with any changes that might be happening in the curriculum. Whilst this sometimes is a challenge, I am always grateful to the tutors for their continued support.

Just as the students work and study hard, I am conscious that Meducate Academy’s ACEs put in the same effort. We will therefore continue to work closely with Chester University and Wolverhampton University to produce high quality training programmes for both communication skills and systems examinations this year.

We are about to start producing video and online resources materials for our ACE training programme over the summer months. In less than a month our ACE Aide Memoire will be available to all of our staff here at Meducate Academy.

It's always fun working with ACEs at The University of Chester
Bob & Mark enjoy working at The University of Chester

Academy continue to invest in our ACEs and we are still working on gaining some type of accreditation for the role. Although we are seen as lay educators our ability to provide high fidelity simulations and clinical skills is well documented by the institutions we work with. It is about time this was rewarded with some type of recognised qualification. It also means that our partners know that they are getting the highest quality ACEs working alongside their clinical staff.

We have always been passionate about continued professional ACE training and we want the quality of that work to be second to none.

We will be rolling out a regular annual training camp for the ACEs. This means we have control over the quality of the people we provide to our customers. This of course will be dependent on social distancing rules being relaxed in the coming months.

If you want to work as an ACE and be part of the team at Meducate Academy enter your details in the landing page here and we will get in touch.

Incidentally we will also be hosting an Annual Conference in July 2021. The panel will consist of five speakers all senior clinicians in their own right who have an impressive track record on the UK PA programme. The topic will be the role of simulation in medical training, specifically focusing on the role of the associate clinical educator.

 

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.

The Associated Clinical Educators Role In Providing Feedback To Student Clinicians

 Associated Clinical Educators Providing Feedback To Student Clinicians

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

Alfred Korzybski the developer of General Semantics once said:

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

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

They can’t.

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

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

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

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

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

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

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

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

You can’t do this with an actual patient!

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

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

“Oh. That was Good!”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Clinical Communication and History Taking – An Associate Clinical Educators Perspective

It’s always important for an ACE to understand the protocols health professionals must follow to help them take a good history from a patient. Once we understand this we are able to give hi-fidelity feedback to the Clinician and thus help them improve their ability to build rapport and gather information simultaneously.

Last week I had the pleasure of working with our partners at The University of Chester and The University of Wolverhampton Physician Associate Programmes.

At Chester University  we worked with 1st Year physician associates and at Wolverhampton we were working with 2nd year students. In both cases we were looking at how students communicate effectively with patients. What was apparent is the importance of quality feedback to the student.

For the students at Chester this was their first time looking at role-play, it was difficult convincing shy students to step up to the plate and hear their thoughts. It turns out that the ACE also has to be something of a motivator encouraging the students to take part. To get to grips with the scenario and to see that “roleplay” can be fun and educational, rather than scary and intimidating. It is this element of teaching that I particularly enjoy.

Wolverhampton however was very different, but still had its challenges. Although the students were more experienced with role-play and history taking, we still had a lot of work to do as the scenarios were far more challenging.

This week however, they had a reprieve from taking part in role-play.

I had been asked by the clinical lead Pete Gorman to deliver a session on communication theory and to talk about the practical challenges students face when talking to a difficult patient.

Whenever we communicate we interact both verbally and non-verbally, and understanding how we can make this work would take more than this short article. Here is a brief synopsis of what we discussed.

There are four legs to effective communication and these are:

  • Rapport
  • Behavioural Flexibility
  • Sensory Acuity
  • Knowing your Outcome

Rapport is key to successful communication. Indeed without rapport it is very difficult to influence anyone, whether that be to make behavioral change or to take a simple history. We have all had that experience with another person when we feel we just connect. We sometimes find ourselves engaged in a conversation with a stranger and feel that they are just like us. That is rapport. People deeply in love have rapport to the extent that they mirror each others’ posture, language and even breathing patterns. That is rapport.

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

In order to be effective in our communications with patients we must also be aware of the continuous process of feedback. It is important to know whether we are getting what we want from our communication. To do this effectively we must have sensory acuity. We notice  changes in physiology, breathing, eye accessing and language patterns. Armed with this information we can build rapport more authentically and deepen the relationship with the patient.

Once we have noticed these seemingly imperceptible cues, we can help the patient make better decisions and connect fully with the health professional. Using these tools will allow the clinician to help the patient to have a greater awareness of the choices available to them in the present, rather than have these choices restricted by past experiences and out-dated responses. This is what we sometimes call motivational interviewing.

Finally, everything you achieve is an outcome. If you are successful in your endeavours; that is an outcome. If you don’t succeed, that is still an outcome. Whatever we do results in an outcome. In order to achieve desirable outcomes we need to effectively model what works and then go out and do it! Rehearsal through role-play is the key to achieving positive outcomes when taking a history. You will always get what you ask for! Ask in the correct way and you will achieve your goal.

Whilst all of the above should be noted there are other important considerations that a clinician should be aware of in history taking.

I asked the students to remember the following when taking a history.

  • Presenting complaints – This is a list of the main symptoms or problems.
  • History of presenting complaint – This is an in-depth description the the presenting compliant.
  • Previous medical history – This is a comprehensive list of the all the illnesses, conditions and operation the patient has had in the past.
  • Drug history – A list of all of the patients medications and any allergies they may have.
  • Family history – Ask about conditions that run in the family.
  • Social history – This includes information about home, occupation, hobbies and habits. This would include smoking, drinking and illicit drug use.
  • Systems review – This a checklist of closed questions for every organ system in the body.

Using open and closed questions is an important skill. Closed questions at the start of a consultations encourage short yes and no type answers. Not good for building rapport in the opening stages of a meeting. Open questions encourage the patient to talk and that can be useful. Save the closed questions for gathering a quick response.

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

A common question I get from students is what factors hinder good communication? The list is extensive and I’ve seen and heard them all, but here are a few.

A badly worded introduction where you don’t clearly say your name. Not remembering the patients name, embarrassment, lack of curiosity, not asking the right types of questions, not making the right amount of eye contact, misreading body language, making assumptions, not listening actively, missing cues, not knowing how to deal with an answer, an over talkative patient, misunderstandings, making assumptions about the patient, stacking questions, judgemental behaviours. There are so many!

At the end of the session I gave students strategies to go away and practice. We always have opportunities every day to practice our communication skills. Unless you’re a hermit of course!

Check out the interactions between Mark and Bob on the video and if you are an actor interested in becoming a medical role-player and want to take it to the next level get in touch and join our growing ACE team. We will be posting dates for the next ACE training soon.

Meducate Academy: Building Lasting Partnerships

Bache Hall, University of Chester
Bache Hall was the venue for this years Summative OSCEs for the 2nd year physician associates

What a great week we have had this week.

We started the week with a mixture of Summative OSCEs for The University of Chester and ended the week with a long day of filming MSK examination procedures for The University of Wolverhampton.

The University of Chester Physician Associate Programme, under the guidance of Course Director James Ennis, were running a series of online and in person Summative OSCEs for their 2nd year students.

We had seven ACEs working on a variety of stations. I was personally responsible for being in Chester taking two days out to work alongside senior clinicians working on Suicide Assessment and Breaking Bad news scenarios.

Preparing for a days filming with Wolverhampton University
Setting up the scene and preparing for filming at the Meducate Offices

The team of ACEs from Meducate Academy gave a great account of themselves and all received glowing testimonials from the Clinicians they were working with. We had no problems with the technology and Chester University has mastered the art of working on Microsoft Teams to great effect. Even the students commented on how well organised the two days went.

Running OSCEs is always a challenge for both Meducate Academy and the universities involved. Our extensive experience working in this fields for over ten years ensures that we always deliver the best service.

Our close working relationship with Chester University means no matter what happens we all work together as a team to ensure the students have the best possible educational experience. I always know that things are going well when individual students remember the names of our ACEs and ask for them by name. It’s also important to build relationships with the students.

Friday morning saw Meducate Academy back in our offices in Birmingham, filming a whole range of Musculoskeletal Examinations for The University of Wolverhampton in preparation for their 2021 teaching modules and the start of their new cohort in February.

Course Lead Pete Gorman and myself filmed Hip, Knee, Shoulder, Spine, Wrist and Foot exams in great detail with explanations of how they can be adapted when demonstrating them on an OSCE station. Safe practice was always the main focus of the sessions, and we made mention of the importance of accurate communication with the patient.

Clinical lead Pete Gorman prepares to preform a hip examination
Clinical lead Pete Gorman prepares to preform a hip examination on the ACE at Meducate Academy

Although the day was long it was made easier by the shared sense of humour of both Professor Kenny Langlands (Course Director), Pete Gorman (Course Clinical Lead) and the team from Meducate Academy.

We also managed to film a short interview with Kenny and Pete as to how they see their close relationship with us and how important the ACE role is with regard to the development of the student Physician Associate.

The films are now in the film edit process and I shall work on this all week.

I’d like to take this opportunity to thank all of our friends and colleagues at both The University of Wolverhampton and the University of Chester for making 2020 a significant year for us, despite the restrictions placed on us by a series of Lockdowns.

2021 could be our best year yet.

Why not join us!

If you are a roleplayer, actor or clinician and wish to be part of the Meducate Team contact us by sending your name and email in the box below.

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.