1. The Clinical Communication and Learning Skills Unit HEA-01 Workshop Supporting students who are struggling academically: one medical schools approach Jo Brown & Dason Evans 12

2. 12 The Clinical Communication and Learning Skills Unit Plan for the day 10:00-11:00 Introductions Defining the problems 11:00-11:15 Coffee 11:15-12:30 Why bother? What is done elsewhere? 12:30-1:30 Lunch 1:30-2:30 The Academic support programme at Barts and the London. 2:30-3:45 How useful is this model to other institutions 3.45-4.00 Close

3. 12 The Clinical Communication and Learning Skills Unit Defining the problem

4. 12 The Clinical Communication and Learning Skills Unit Examples Student 1: an excellent student academically, fails her first Clinical Skills OSCE. She has a deep learning style for theoretical knowledge but an inappropriate learning style for clinical skills. We provided her with sessions on how to learn clinical skills.

5. 12 The Clinical Communication and Learning Skills Unit Examples Student 2: fails his third year theory exams with a very poor score. He had excellent A-levels, good year one exams and reasonable year two exams. He turns out to have an excellent short term memory and a superficial learning style. The volume of work is finally too much to cram and he fails. We provided him with sessions encouraging a regular habit of self directed learning.

6. 12 The Clinical Communication and Learning Skills Unit Examples Student 3: a previously excellent student fails her third year clinical skills OSCE. She has no insight into the fact that she is clinically depressed. Her attendance has been poor, but she is academically strong as she starts bookwork when she wakes at 3am every morning. We arranged an urgent GP and psychiatry appointment.

7. 12 The Clinical Communication and Learning Skills Unit Examples Student 4: an international student fails her clinical skills exam, saying she didnt know what to expect More to come!

8. 12 The Clinical Communication and Learning Skills Unit Examples Student 5: Fails his clinical skills exam scoring poorly on communication skills stations He finds talking to patients difficult, as he isnt sure exactly what information he needs to gather and how he might go about this in a time-limited fashion. We went with him to the wards on two occasions and using video tape review helped him gain structure and confidence in talking to patients.

9. 12 The Clinical Communication and Learning Skills Unit Your examples

10. 12 The Clinical Communication and Learning Skills Unit Common problems at Barts and the London

11. 12 The Clinical Communication and Learning Skills Unit Why Bother?

12. 12 The Clinical Communication and Learning Skills Unit Why do we bother? Ethical and moral duty to students. Socio-political culture of accepting and responding to individual differences. Obligation and responsibility to future patients. –( philosophy of ASP – Not a revision course) –GMC Producing Life Long Learners. Belief that students who have been supported through difficulty may end up better doctors. –Coping mechanisms –empathy School philosophy to: –meet the needs of students –produce graduates… who are fit for the nation's present and future health, research and health care needs. Financial –benefits (widening access) –penalties (attrition rates)

13. 12 The Clinical Communication and Learning Skills Unit Group Work 1 Group 1 How are struggling students identified in your institution? Group 2 How does your institution work out the reasons that students struggle? Group 3 What interventions does your institution put in place to support struggling students? Group 4

14. 12 The Clinical Communication and Learning Skills Unit Group work 1

15. 12 The Clinical Communication and Learning Skills Unit Lunch

16. 12 Support for Students with Academic Difficulties

17. 12 The Clinical Communication and Learning Skills Unit Overview of Presentation Macro Micro Macro Background to the school Background to the A.S.P. Model Specific Case History Validation of programme Looking to the future

18. 12 The Clinical Communication and Learning Skills Unit Background to Barts and the London An ancient and amalgamated medical school A spiral curriculum Curriculum revised in 1999: – –Problem Based Learning running throughout the curriculum – –Early clinical experience in the community – –Explicit teaching of Communication and Clinical Skills

19. 12 The Clinical Communication and Learning Skills UnitAssessment Clinical skills OSCE Data interpretation Written Assessment Continuous assessment Year 1 Year 2 Year 3 Year 4 Year 5

20. 12 The Clinical Communication and Learning Skills Unit Background and History To ASP Began in 1999 when committed teachers began to give detailed feedback to students about their exam results and offer clinical skills workshops. Previously informal and variable support from senior tutors, concerned and interested faculty Formalised and funded in 2002, the ASP has grown to provide student centred support for learning. Now represented on all major educational committees and produces an annual report.

21. 12 The Clinical Communication and Learning Skills Unit Formalised & embedded in curriculum ASP CCLSU Assess Teaching Education Directorate Dean for Education Medical School Dean for Student Affairs and senior tutor system

22. 12 The Clinical Communication and Learning Skills Unit The system Indirect Direct Educational Assessment interview Free discussion Semi-structured interview Fine-tooth analysis of assessment results Poor Performance in Summative Assessment Principally JOSCE & 3 rd year EMQ Senior Tutor Referral Student request Poor performance in continuous assessment Other No action E.g. precipitating problem resolved or obtaining academic support elsewhere Ongoing Individual Tuition Aimed at supporting self- directed Learning either in clinical skills or theoretical background to medicine. Always student led. Problem List Action Plan Learning Contract Short Courses: Learning style Aimed at encouraging a change in learning style, 1 how to learn clinical skills 2 Reflective communication skills 3 exam (eg MCQ) technique 4 anxiety management 5 others Specific Suggestions To Students, Senior tutors, tutors or firms Referral Elsewhere Medical referral Educational psychologist Learning support unit ReferralAssessmentIntervention

23. 12 The Clinical Communication and Learning Skills Unit Educational Assessment Interview Free discussion about reasons for poor performance How he/she learns –Knowledge –Skills –Self directed learning –Collaborative learning Fine tooth-comb analysis of assessment results Screening questions –Motivation Scale of 1-10 What sort of doctor? Enjoy the course? –Attribution Have you received enough teaching? Was the exam a fair exam? Is mark representative of performance? –Pastoral Medics in the family? Received enough support? –Working with patients –Problems attending

24. 12 The Clinical Communication and Learning Skills Unit The system Indirect Direct Educational Assessment interview Free discussion Semi-structured interview Fine-tooth analysis of assessment results Poor Performance in Summative Assessment Principally JOSCE & 3 rd year EMQ Senior Tutor Referral Student request Poor performance in continuous assessment Other No action E.g. precipitating problem resolved or obtaining academic support elsewhere Ongoing Individual Tuition Aimed at supporting self- directed Learning either in clinical skills or theoretical background to medicine. Always student led. Problem List Action Plan Learning Contract Short Courses: Learning style Aimed at encouraging a change in learning style, 1 how to learn clinical skills 2 Reflective communication skills 3 exam (eg MCQ) technique 4 anxiety management 5 others Specific Suggestions To Students, Senior tutors, tutors or firms Referral Elsewhere Medical referral Educational psychologist Learning support unit ReferralAssessmentIntervention

25. 12 The Clinical Communication and Learning Skills Unit

26. 12 Questions on process

27. The Clinical Communication and Learning Skills Unit Case study Referral

28. 12 The Clinical Communication and Learning Skills Unit Case Study: Referral I An international student fails her clinical skills exam, saying she didnt know what to expect. Came in the lowest 5% of cohort Failed 12 out of 19 stations Previously received A and B grades for her written exams

29. 12 The Clinical Communication and Learning Skills Unit Score

30. 12 Number of stations passed

31. The Clinical Communication and Learning Skills Unit Case study Educational Assessment Interview

32. 12 The Clinical Communication and Learning Skills Unit Case Study: Diagnostic I Fine tooth analysis

33. 12 The Clinical Communication and Learning Skills Unit

34. 12

35. 12 Semi-structured interview General questions –Lives in international halls –Rarely mixes with students of other nationalities –Rarely uses conversational English –Home sick, isolated and unsure if she really wants to study medicine in the UK

36. 12 The Clinical Communication and Learning Skills Unit Semi-structured interview Learning Methods – declarative knowledge –Works 3-4 hours a week SDL –Relies on memory of reading from text books –Reads with TV or radio on Learning Methods - skills –Has used clinical skills lab (alone) –Uses one skills book and handouts –Clerks 2 patients a week if I am pushed –Found third year unstructured

37. 12 The Clinical Communication and Learning Skills Unit Semi-structured interview Specific questions –Is motivated to be a Dr –No medics in the family, much pressure to succeed from her government –Doesnt feel there has been enough teaching –sometimes finds difficulty approaching patients

38. The Clinical Communication and Learning Skills Unit Case study Problem List

39. 12 The Clinical Communication and Learning Skills Unit Problem List Not fully committed to course, not working Social isolation –Language –Collaborative learning –Loneliness Study skills –Limited for theory to simply reading –Poor model for learning clinical skills Never seeks feedback Limited amounts of practice

40. 12 The Clinical Communication and Learning Skills Unit Common problems at Barts and the London

41. The Clinical Communication and Learning Skills Unit Case study Negotiated learning contract

42. 12 The Clinical Communication and Learning Skills Unit Learning Contract 1.Consider if she wants to be a doctor 2.Consider if she wants to continue training in the UK If she wishes to remain 1.Clerk a minimum of 5 patients a week 2.Study a minimum of 2 hours a night 3.Commit to work collaboratively with retake group 4.Move into college halls 5.Integrate with other students from the medical school

43. The Clinical Communication and Learning Skills Unit Case study Intervention

44. 12 The Clinical Communication and Learning Skills Unit Case Study: Interventions Clinical Skills –Extra clinical skills tuition –Clinical skills study skills –Supportive ward placement Communication Skills Collaborative learning Pastoral

45. The Clinical Communication and Learning Skills Unit Case study Outcomes

46. 12 The Clinical Communication and Learning Skills Unit Case Study: Outcomes I Exam Success/Competency Ongoing success PastoralSmiling!

47. 12 The Clinical Communication and Learning Skills Unit Score

48. 12 Number of stations passed

49. 12 The Clinical Communication and Learning Skills Unit Case Study: Outcomes III 64% 62% 64% 60% Knowledge test Data Interpretation test Skills testContinuous assessment

50. 12 The Clinical Communication and Learning Skills Unit Finals 2005 65%

51. 12 The Clinical Communication and Learning Skills Unit Questions on Case Study

52. 12 The Clinical Communication and Learning Skills Unit Validation Student evaluation Independent evaluation Exam results Links to curriculum & institution Publications & presentations

53. 12 The Clinical Communication and Learning Skills Unit Validation: student evaluation

54. 12 The Clinical Communication and Learning Skills Unit I felt that it (assessment interview) didnt put me down, didnt make me feel thick They (ASP staff) went through all the exams we had done and really allowed us to explore how we do them (In the assessment interview) They are kind and listening and paying attention…I could take the first positive step after that…the interview itself is part of the intervention They (ASP staff) are very friendly, very approachable and very easy to talk to Qualitative comments I did go to my senior tutor but no-one was asking the right questions… not getting to the root of the problem

55. 12 The Clinical Communication and Learning Skills Unit Validation: Formal independent evaluation Educational psychologist evaluation –Video review –Document review –Focus group and individual student interviews –Faculty interviews –Educational literature review The outcomes and processes of the educational assessment and subsequent support are highly effective

56. 12 The Clinical Communication and Learning Skills Unit [The course] increased my confidence on the wards [The course gave me] insight into a more thorough way of learning Thank you for the work you have all put in. It has been a great course & I will be very grateful in the long run Taught me to analyse myself I am very nervous about Tuesday [the retake exam], but would have been more if I did not have … the retake course in place Qualitative comments

57. 12 The Clinical Communication and Learning Skills Unit Exam results Are exam results an appropriate surrogate marker for outcomes of an Academic Support Programme? Students failing OSCEs do well, and continue to do well after passing through ASP (from bottom 5% to average).

58. 12 The Clinical Communication and Learning Skills Unit Validation: exam results 49.1 62.9

59. 12 The Clinical Communication and Learning Skills Unit Validation: exam results 10.4 16.2

60. 12 The Clinical Communication and Learning Skills Unit Continuing success Of the 16 students who failed their third year OSCE in 2002, all passed through a modified academic support programme, 9 took finals in 2004. Their mean OSCE score at finals was no different from the rest of the cohort (p=0.52, Scheffe post hoc analysis), Compare with the lowest 17 students passing the third year OSCE, 9 took finals in 2004 and performed significantly worse than the rest of their cohort (*p=0.029 Scheffe post hoc analysis from ANOVA).

61. 12 The Clinical Communication and Learning Skills Unit

62. 12 Validation: Reporting and Liaison Medical Education Committee Student Affairs Board Senior Tutor system Queen Marys Learning Support Unit

63. 12 The Clinical Communication and Learning Skills Unit Validation: Publications & presentations ASME conference: Identifying and supporting medical students with communication difficulties; June 2005, London First International Clinical Skills Conference – 2005 Prato, Italy. Educational psychologist input - 2005 CETL - 2005 Presentation at 11 th Ottawa international conference on medical education, 2004 Drapers award for excellence in teaching & learning 2004 Example of good practice at the LTSN-01 National Meeting of Medical Curriculum Co-ordinators 2002 Sayer M. Chaput de Saintonge M. Evans D. Wood D. Support for students with academic difficulty. Medical Education. 2002 July;36(7):643 – 650. ASME: Association for the Study of Medical Education Annual Scientific Meeting 2000, Dublin.

64. 12 The Clinical Communication and Learning Skills Unit The future Publications Focus on faculty development Focus on dissemination

65. 12 The Clinical Communication and Learning Skills Unit Summary Students always have, do and always will struggle They struggle for a wide variety of reasons Remedial programmes should be personalised to meet individual learning needs Successful remedial programmes are resource- intensive and require institutional support for success There are exciting opportunities for further development and dissemination of this programme.

66. 12 The Clinical Communication and Learning Skills Unit Questions

67. 12 Group Work 2 Group 1 What do you think are the most transferable aspects of this Academic Support Model to your own institution? Group 2 Group 3 Group 4

68. 12 The Clinical Communication and Learning Skills Unit Group Work 2

69. 12 The Clinical Communication and Learning Skills Unit Close Academic Support Network Goodbye and safe journey home!

70. LTSN-01 Workshop Supporting students who are struggling academically: one medical schools approach Jo Brown Dason Evans 12