Fourth International Clinical Skills Conference

Prato, Tuscany 22 - 25 May 2011

Speakers

	Dr Peter Dieckmann Dr. Peter Dieckmann is work and organisational psychologist with the Danish Institute for Medical Simulation in Herlev, Denmark. He received his PhD in in 2005 from the University of Oldenburg in Germany, in a collaboration with the Swiss Federal Institute of Technology in Zurich with a work on using simulation in anaesthesiology. He has published several other relevant publications. His main focus areas are theoretical foundations of simulation-based education, training, and research, instructor and facilitation education, human factors and experienced based learning in and beyond health care. Peter is currently the President of the Society in Europe for Simulation Applied to Medicine (SESAM). With two colleagues, Peter co-chairs the upcoming International Meeting for Simulation in Health Care (IMSH 2011), the world's largest simulation meeting to date, attracting approximately 2500 participants. View Keynote Address - Simulation-Based Education: Theory and Practice Simulation-based education has much potential in health care, but also limitations. This keynote explores relevant theoretical concepts for an optimized use of simulative methods in health care education and training. What position can simulation have in an adult learning concept and what theoretical frameworks can inform the conduction of simulation-based education? Simulation can be an integrative part of any experiential learning setting, but at the same time poses some challenges for educational alignment of the different stakeholders involved (commissioners, trainers, participants). To fully use this potential, the simulation setting as the context of the learning experience needs to be optimized with having the educational goals in mind. Different elements of any simulation setting interact with each other and depend on their joint optimisation. Simulation instructors need to optimize the conditions for learning and do all they can to help participants to learn. On the other hand instructors cannot “make” participants learn thus it is necessary to clarify the mutual expectations, tasks and responsibilities. In terms of practical implications, at times the “gear” can get in the way of optimized learning. Often the possibilities and limitations of simulation devices and the clinical experiences of the instructors provide the guidance for the design and conduction of simulation settings – not the educational goals. Based on the exploration which educational goals might be achieved with simulation and based on the theoretical foundation practical implications for simulation-based education will be described. While the talk will focus on manikin-based simulation, principles are applicable also for other simulation modalities. View Keynote Workshop - Creating, recognizing and using learning opportunities: Goal-oriented simulation Using simulation in a goal-oriented way means to base the design and implementation of simulation-based education on the educational goals, while at the same time keeping and open mind for learning opportunities that might arise on the way. The simulation team creates learning opportunities – the participants decide, whether they actually use those. Creating is done during the design and implementation of curricular, courses, scenarios, and debriefings. Recognising learning opportunities requires content expertise and awareness of the simulation team. What do actions, utterances and questions of the participants tell the instructors about their knowledge, skills, and attitudes? Do they imply misunderstandings that might need to be corrected? Do they imply brilliant solutions for problems that should be emphasised? Using those learning opportunities means to adjust simulations to the states and traits of participants and base any kind of debriefing on the educational goals. During the workshop we will use a simulation setting based on a low fidelity simulation-oriented exercise to explore how learning opportunities can be designed, created and used. The exercise can be replicated easily and at the same time provides for rich learning both about complex tasks performed by a group of people as well as the design and implementation of simulation settings. Experiential parts in the workshop will be mixed with reflective parts.
	Dr Stuart Marshall Stuart Marshall is a Specialist Anaesthetist working at Southern Health and Peninsula Health Hospitals in Melbourne. Having started his anaesthetic training in Leicester in the UK, he moved to New Zealand and then Australia in 2002. Whilst studying for a private pilot’s licence he became interested in aviation safety, the training of aircrew, and reducing the incidence and minimising the effects of errors. This interest ultimately led to a position in simulation education, and research into how this mode of training can assist in the development of non-technical skills. He completed a Masters Degree in Human Factors/Ergonomics in 2008 and is currently a PhD candidate with the University of Queensland’s Cognitive Engineering Research Group (CERG). His research interests include the use of simulation education to teach patient safety in undergraduate and postgraduate curricula, and the use of cognitive aids in medical emergencies. As a crisis resource management instructor and the lead researcher at the Southern Health Simulation and Skills Centre, he teaches on a variety of courses, including medical and nursing disciplines from undergraduates to specialists. He teaches the airway management module of the Monash University short course in Peri-operative medicine, and has co-authored local and national undergraduate and postgraduate patient safety courses. View Keynote Address - Learning, forgetting and implementing: Challenges in implementing innovation in health education We all start off with good ideas and best intentions to implement our innovations. In health education that generally means improving safety though education of our patients, colleagues and junior health professionals. Unfortunately the application of these ideas can go astray, and we don’t quite see the effect on practice and in the workplace that we had hoped for. Why is this? Are there patterns that are playing out preventing our ideas from reaching their intended potential? In 1869 Thomas Alva Edison patented his first invention, the electronic voting machine designed for use in the US Congress. Despite the apparent need for such a device the machine was never sold or used. The political environment at the time was more heavily based on lobbying, meeting and talking to political allies and adversaries. Removing the politician from the required day-to-day social interactions would require a big cultural shift that the political system was not ready for. Furthermore, improving the efficiency of the process would prevent politicians from using delaying tactics to block new legislation. Edison had made the mistake that many medical educators continue to make today; he thought that everyone else would see the benefits of a new way of doing things, and he ignored the existing social and cultural factors of the workplace. The ‘Medical Emergency Team’ (MET) or ‘Rapid Response Team’ (RRT) is an example of a good idea that has gone awry in the health workplace. The notion is that abnormal physiological measurements such as blood pressure and oxygen saturations can trigger a specialist team to respond and troubleshoot why the patient has become critically unwell. Studies looking at individual patient outcomes following a RRT call have shown marked improvements in survival¹. Conversely, this improvement has not been translated into reductions in mortality and cardiac arrest on an institutional scale following implementation. The reason appears to be the very low usage of the RRT despite attempts to mandate its use². Hospital Rapid Response Systems seem to be failing for the very same reason that Edison’s voting machine failed; they have been implemented with no regard to the existing workplace culture or the way work is done. How can we learn from Edison’s successes and the emerging literature of ‘knowledge translation’³ to help implement our innovations? In this presentation I will explain how we, as educators and clinicians, can ensure good ideas are transferred to the workplace where they can have real results. Using the example of the Medical Emergency Team, I will show how a well-meaning but ineffectual implementation of a good idea can be salvaged and eventually lead to improved patient safety in clinical settings. References Chen J, Bellomo R, Flabouris A, Finfer S: The relationship between early emergency team calls and serious adverse events. Critical Care Medicine 2009, 37:148-153. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C: Rapid response teams: A systematic review and meta-analysis. Archives of Internal Medicine 2010, 170:18-26. Straus SE, Tetroe J, Graham I: Defining knowledge translation. Canadian Medical Association Journal 2009, 181:165-168. View Keynote Workshop - “Safety doesn’t happen by accident”: How can we optimise the learning environment to be non-threatening for our participants? Facilitators: Stuart Marshall Jennifer Hogan Sue Ballinger-Doran Southern Health Simulation Centre, Melbourne Description: “Q: Did the simulation session evoke any strong emotions for you today? A: Yes, stress, anger and frustration...” How as educators can we prevent these negative emotional reactions to simulation-based education? Preparation of the faculty and participants, appropriate structuring of the session and scaffolding of learning over the course can help, but what is the evidence? This workshop will challenge the participants to explore the aspects of creating a safe learning environment when using simulation-based education. Target Audience: Simulation and Clinical Educators. Intermediate level experience Presenters: All three presenters are experienced simulation educators from the Southern Health Simulation Centre in Melbourne. Jen Hogan has undertaken research into participant safety in ‘pause and discuss’ education techniques. Sue Ballinger-Doran has previously investigated how familiarisation to the simulation environment affects the emotional state of participants. Stuart Marshall has a research interest in educational techniques to improve patient safety.
	Professor Charlotte Rees Charlotte Rees is a social scientist and educationalist by background. She is Professor of Education Research and Director of the internationally renowned Centre for Medical Education at the University of Dundee, UK. Charlotte has held previous positions as Associate Professor at the Sydney Medical School, University of Sydney, Australia; Senior Lecturer and Foundation Academic Lead for Human Sciences, Communication Skills and Professionalism at Peninsula Medical School, University of Exeter, UK; Lecturer at the Nottingham Medical School, University of Nottingham, UK. For 10 years, Charlotte has developed a program of research about patient-centered professionalism in medical education. Her current and future plans for research include exploring healthcare students’ professionalism and professional identity formation and student-patient-tutor interaction in the healthcare workplace. Although she has extensive experience with quantitative research methods, her methodological approach largely draws on qualitative methods currently. Charlotte is particularly interested in innovations in qualitative data analysis in medical education research such as systematic metaphor, discourse and narrative analysis. She is Deputy Editor for the highest ranked education journal (scientific disciplines) Medical Education and has published over 60 articles across a broad range of journals including Medical Education, Academic Medicine, Social Science & Medicine, Communication & Medicine and Qualitative Health Research. View Keynote Address - Learning clinical skills in the workplace: creating professionalism dilemmas for healthcare students? There has been much discussion within the medical education literature about inter-related aspects of the curriculum (formal, informal and hidden) and how these interplay within healthcare students’ learning.¹ With the advent of formal curricula for clinical skills learning (e.g. simulation), students are commonly placed in professionalism dilemmas while learning clinical skills as part of the informal and hidden curriculum (i.e. the clinical workplace).² Research into clinical skills learning has often focused on the formal curriculum—most notably technical issues from an individualist perspective such as the assessment of students’ clinical skills and the teaching of clinical skills through simulation.^3-4 Instead, this presentation pays attention to probably the most under-researched aspects of the curriculum—the informal and hidden curriculum—and how clinical skills are learnt by medical and other healthcare students in the clinical workplace. Underpinned by an interactionist/social rather than individualist perspective, Charlotte will use examples from her collaborative program of research with medical and healthcare students’ professionalism dilemma experiences in four countries (England, Wales, Scotland and Australia) to illustrate the conflicts between the formal and the informal/hidden curriculum for clinical skills learning and how these conflicts can create professionalism dilemmas for our students.² Instead, Charlotte will argue for a shift from conflict to complementarity between the formal, informal and hidden curriculum and will provide various recommendations on how this may be achieved.^2,5 References Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Academic Medicine 1998;73:403-407. Rees CE, Monrouxe LV. Medical students learning intimate examinations without valid consent: a multicentre study. Medical Education 2011, doi:10.1111/j.1365-2923.2010.03911.x. Issenberg SB, McGaghie WC, Petrusa ER, Gordon DL, Scalese RJ. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Medical Teacher 2005;27:10-28. Rushford HE. Objective structured clinical examination (OSCE): Review of literature and implications for nursing education. Nurse Education Today 2007;27:481-490. Rees CE & Monrouxe LV. “Oh my God uh uh uh”: Laughter for coping in medical students’ personal incident narratives of professionalism dilemmas. In: CR Figley, P Huggard & CE Rees, First do no self-harm: Understanding and promoting physician stress resilience. New York: Oxford University Press; forthcoming. View Keynote Workshop - Qualitative innovations in medical education Bedside teaching within the medical workplace is considered essential for helping students develop their communication, physical examination and procedural skills, clinical reasoning and professionalism.¹ Bedside teaching encounters (BTEs) involve the ‘learning triad’ of patient, doctor and student.² However, observational research relating to how students, patients, and doctors learn with, from and about one another within BTEs is scarce.^2-5 This research typically employs qualitative methods that are fairly innovative within medical education research e.g. audio and/or videotaped observation of BTEs and discourse analysis of those interactions.^2-5 In this workshop, Charlotte will discuss these innovative methods of collecting and analysing data from the medical workplace to explore how students learn clinical skills. Workshop participants will discuss the strengths and challenges of collecting and analysing this type of data. Participants will also gain practical hands-on experience of analysing interactional data from BTEs and comparing, contrasting and negotiating their analyses with each other. References Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Medical Teacher 2003;25:127-130. Rees CE, Monrouxe LV. “Is it alright if I-um-we unbutton your pyjama top now?” Pronominal use in bedside teaching encounters. Communication & Medicine 2008;5: 171-182. Monrouxe LV, Rees CE, Bradley P. The construction of patients’ involvement in hospital bedside teaching encounters. Qualitative Health Research 2009;19: 918-930. Rees CE, Monrouxe LV. “I should be lucky ha ha ha ha”: The construction of power, identity and gender through laughter within medical workplace learning encounters. Journal of Pragmatics 2010;42: 3384-3399. Ajjawi R, Rees CE, Monrouxe LV, Wilson I. Triadic interaction in bedside teaching encounters in primary care: A video-observational study in Australia. AMEE conference, September 4-8, 2010, Glasgow, UK, p. 49.
	Professor Janice Rymer Janice Rymer is Dean of Undergraduate Medicine and Professor of Gynaecology, King’s College London School of Medicine. She qualified with an MBCHB in 1981 from the University of Auckland, she became a member of the RCOG in 1987 and fellow of the FRANZCOG in 1990. She was made a fellow of the RCOG in 2005. Professor Rymer’s areas of special interest are Minimal Access Surgery, Ovarian Failure, Female Genital Mutilation and Medical Education. She has run the Menopause Research Unit at Guy’s and St. Thomas’ Hospital since 1990. From 1991 to 2010 she held responsibility for the organisation of undergraduate teaching in Obstetrics and Gynaecology, first at UMDS then Guy’s, King’s and St Thomas’ and now King’s College London School of Medicine. Her publications comprise over 100 peer-reviewed papers, and 14 textbooks. Extramural positions include Member of the RCOG Council (1997-2005, 2010- ) and Member of the British Menopause Society Council (1986-1992, 2010- ). Currently she sits on the Academic Committee and serves as Recruitment Officer for the RCOG. She is also on the General Medical Council team for assessing new medical schools. View Keynote Address - Sharing the best evidence in the use of clinical skills education and practice Clinical skills and communication skills cannot be separated. An intimate examination is probably the most challenging skill to teach to a medical student. Historically the skills of intimate examination have been learnt in breast, gynaecology, genitourinary medicine and/or surgical clinics. This is not the best environment for learning because these clinics are generally overbooked, and there is little time for teaching. Communication between instructor and student is inhibited by the presence of the patient since the primary purpose of the consultation is for the patient’s benefit. The patients are usually anxious about the prospect of an intimate examination and the student’s anxiety may be even greater. Teaching intimate examinations has also relied on students practising on anaesthetised patients but this introduces a conflict between educational needs and ethical requirements The use and development of mannequins for teaching clinical skills has been a major advancement in medical education, however mannequins alone don’t address the teaching of communication skills. Patients’ involvement in medical education is clearly the way forward and an ideal learning model would perhaps begin with anatomy, and then move onto demonstration with a mannequin, then a half woman/half mannequin to attempt communication skills. The gold standard however would be a real woman trained in pelvic examination who can give feedback on both communication and technical skills in an unthreatening environment. Lay women can put themselves into the place of a patient more easily and appreciate the anxiety or unfamiliarity with medical jargon. Lay woman acting as teachers are in a strong position to communicate these non technical issues to students. Other models for patient educators include senior citizens acting as models for breast examination, and cancer survivors. Peer physical examination, in which students examine areas of each other, appears to have its limits and students have particular anxieties about intimate regions based around sexual, gender, religious and cultural concerns. An alternative might be the use of a virtual patient, designed with the specific aim of enhancing communication skills; a life size avatar, modifiable for different ages, races and constellation of symptoms, projected onto the wall of the examination room with speech recognition abilities has now been developed enabling interaction between the patient and the student and comments from the avatar. Although this has the attraction of flexibility, this cannot replace the hands on experience that lay teachers can provide. RCT and other evidence is now accumulating in the use of clinical skills education and practice and t is important to disseminate this knowledge and define the gold standard of teaching intimate examination. It is vital that students be made aware of their responsibilities and acknowledge basic professional requirements. Above all they must be aware of the respect that they need to show for the patient and must know their limitations. Lay women appear to be the ideal teachers in this regard. View Keynote Workshop - Setting up a gynaecology teaching associate or breast teaching associate programme Objective: to instruct patients on how to set up a gynaecology teaching associate or breast teaching associate programme. Audience: educators responsible for teaching intimate examination in medical or nursing curricula. Abstract: The teaching of intimate examinations is challenging as it involves communication as well as technical skills. Laywomen have been proven to teach students better than relying on mannequins or training in clinics and operating theatres. There are many barriers to setting up a GTA or BTA programme. Within the workshop these problems areas will be explored and solutions proposed. Summary of qualifications and experience: Janice Rymer MD FRCOG FRANZCOG FHEA Professor in Gynaecology Dean of Undergraduate Medicine Kings College London School of Medicine I have set up the first GTA programme in the UK and have more than 20 years teaching experience. I have published on a RCT for GTAs proving their success by students gaining higher OSCE scores than those who are traditionally trained. I have also done a trial on BTAs. I have run a workshop at the Ottawa conference at New York regarding RCTs in medical education. Maximum participants – 20 Equipment required: power point facilities
	Jonathan Silverman Jonathan Silverman is Associate Clinical Dean at the School of Clinical Medicine, University of Cambridge and a general practitioner in Cambridgeshire. He has been actively involved in teaching communication skills since 1988 and in 1993, undertook a sabbatical with Professor Suzanne Kurtz, teaching and researching communication skills at the Faculty of Medicine, University of Calgary. In 1999 he became Director of Communication Studies for the undergraduate curriculum in Cambridge, which now involves over 600 half day small group sessions per year. He is best known as one of the authors of the Calgary-Cambridge Guides to the Medical Interview, which provide a framework for describing the medical interview and incorporate a comprehensive set of skills referenced to the current evidence. The guides are used in 70% of UK schools. He has also co-authored two companion books with Suzanne Kurtz and Julie Draper, "Teaching and Learning Communication Skills in Medicine" and "Skills for Communicating with Patients" (both Radcliffe Publishing Second Editions 2005). He has conducted communication skills teaching seminars throughout the UK, in Europe and N. America. In 2005, he founded the UK Council for Communication Skills Teaching in Undergraduate Medical Education for all 33 UK medical schools and is now chair of the teaching committee of the European Association of Communication in Healthcare. View Keynote Address - Teaching clinical communication: a mainstream activity or just a minority sport? Over the last 10 years, clinical communication skills teaching has come of age. For those of us working in the field, it has been gratifying to see the increasing acceptance of the subject as a formal component of the medical curriculum. However, the title of this talk “Teaching clinical communication: a mainstream activity or just a minority sport?” suggests there is a problem to be faced. Is communication truly perceived by schools and learners as central to all clinical interactions or is it being taught as a token gesture? The prime focus of this presentation is to take an honest look at the present status of communication teaching and consider how to take the next steps to move communication into the very centre of medical education. This presentation explores why clinical communication often appears to be a minority sport in medical education, considers how to overcome this via integration throughout the curriculum, looks at five specific examples of integration in action Integration with history taking skills Integration with practical skills Integration with specialty teaching Integration with the hidden curriculum The crucial role of assessment in integration and explores the progression to maturity in communication curricula. Because of my own background, I am going to look at this issue from the perspective of undergraduate medical education but I very much hope that what I say will translate into other teaching environments especially postgraduate education and the education of other healthcare professionals. View Keynote Workshop - Feedback in experiential sessions: managing feedback in different learning contexts Purpose: This workshop will focus on providing feedback in experiential skills teaching. It will explore how to give feedback in a variety of teaching contexts. Objectives: As a result of this workshop, participants will be able to: Describe how to structure feedback to learners to enhance learning Implement key components of effective feedback in experiential skills sessions Compare and contrast the differences in feedback approaches depending on the teaching context including one to one, small group, with video review, with and without simulated patients. Rationale: Feedback is a key components of effective skills teaching. Managing the feedback process in a variety of different teaching situations is essential if facilitators wish learners to enhance and change their behaviour in actual clinical practice. Activities: The workshop will be highly interactive, participant-centred and experiential. The material used will focus on communication skills teaching, but be applicable to other skills learning. Participants will first observe a consultation on DVD as if directly observing it in the outpatient setting. They will then in pairs explore what they would emphasise in feedback to the learner. With the use of volunteers from the audience, we will then explore in a sequential fashion how to provide feedback in a variety of teaching contexts including one to one teaching, when video review is available, within small groups and with simulated patients. These approaches will emphasize the benefits of strategies such as learner-centred agenda-led feedback, balanced behaviourally specific feedback and opportunities for re-rehearsal of skills in each of these contexts.