Robert Brodrick – Series 2 - Managing Dying

[00:00:00] Cheryl: Welcome to the podcast from Cambridge University Medical Education Group, or CUMEG for short. This is a podcast from the University of Cambridge Clinical School, focusing on medical education. We discuss a range of topics that medical educators are dealing with. I'm your host, Cheryl France, Head of CUMEG

Today, I would like to introduce Dr. Robert Brodrick. Robert is a consultant in palliative medicine. He's a member of the Royal College of Physicians and has a Master's degree in Medical Ethics and Law. Robert teaches medical students in Cambridge focusing on symptom control, end of life care, and clinical communication skills.

Welcome, Robert. It's wonderful to have you with us today.

[00:00:44] Robert: Thank you.

[00:00:46] Cheryl: Would you be kind enough to tell us more about your background and your current role?

[00:00:50] Robert: Yeah, so I am an Associate Specialty Director in palliative care here at Cambridge, and I'm involved in teaching communication skills and symptom control as you mentioned, but one of my key passions is actually improving end-of-life care training. We know that nationally students don't feel very well prepared when they graduate to look after patients in the last days of their life. And personally, I've got an interest in dying well, when my time comes. I want someone who's really well trained and about 40 patients is the number that medical doctors in the first year of practice have to look after often with not a great deal of support. So, the more exposure we can give our students, the better.

It's a bit different to an analogous field, I guess. Obstetrics medical students will often be present at birth for maybe six, seven births and a very large number of students nationally don't ever see a dying patient.

[00:01:47] Cheryl: Wow.

[00:01:48] Robert: Not a single one because they're just excluded from the bedside. It's too taboo or too sensitive. They're like, it's a bit, feels voyeuristic or something. And yet it's going to be a big part of their working lives. So how do we give them that experience without them being in the room? And this is what the simulation work is all about.

[00:02:08] Cheryl: Wow. That's really interesting. Thank you. That's quite a good way to lead into the podcast today. Because one of the things we'd like to focus on is to understand more about the simulation program that you've been developing here at the clinical school. So, I think that background you gave us, that's quite startling that in the first year there's up to 40 patients that the students will be looking after yet potentially may not have had any experience.

That's a big deal and something that we do need to improve. So, I think it's fantastic that you have been working on this. So, I think my next question is going to be, can you give us a brief explanation about the simulation program that you've developed?

[00:02:55] Robert: Thank you. Yes. So, I think the best way of thinking about multimedia simulation is that it's an interactive story, told through videos and audio clips and texts and photographs where the students play the role of a doctor in this case. An F1 doctor and,

[00:03:13] Cheryl: Sorry, can I just clarify? F1.

[00:03:15] Robert: Oh, a foundation year one program doctor. So, a doctor in the first year following graduation from medical school.

[00:03:19] Cheryl: Excellent. Okay, thank you.

[00:03:20] Robert: And I don’t know if you ever did those choose your own adventure books when you were a child where if you wanted to drink the magic potion, you'd turn to page 13, or if you wanted to speak to the dragon, you'd page, you know, 64 or whatever, and it would loop back on itself. And depending on the choices you make; the story would unfold in a different way. So, it's based on that principle only it's delivered online.

[00:03:45] Cheryl: Okay.

[00:03:46] Robert: So, in this particular scenario, managing dying, which is the first resource we developed here, the students are looking after a patient with advanced pancreatic cancer in an acute medical unit.

[00:03:55] Cheryl: Okay.

[00:03:56] Robert: And they meet her following time in the emergency department and they're in charge of diagnosing what's going on, managing her treatment, making choices. And no student really has the same experience going through the scenario because it unfolds depending on their choices.

[00:04:09] Cheryl: Oh, that's quite interesting. So, it's very interactive in that way of saying, okay, I think I should do X. But that would take you down one scenario versus if you chose a different pattern.

[00:04:22] Robert: That's the idea. Yeah. So, it's maximal student engagement. So, we know that learning is driven by what learners do rather than what learners experience or what they're exposed to. So, a lecture is relatively inefficient way of learning in terms of retention. But a scenario where they play the doctor and every few seconds, they're given a choice that has consequences, will keep them engaged and hopefully generate more learning as a result per unit time.

[00:04:48] Cheryl: Yes. That's really interesting. Okay. Thank you for that.

So, I think it would be useful to understand more about the process of developing a simulation tool because you make it sound like, oh yeah, you just do this, and you do that. But I don't think it goes quite as easily as that. And I think it would be really useful if we could kind of take a step back and say what are the steps that are needed in order to get to a final product? Could you give us some more insight into that?

[00:05:18] Robert: Yes. So, I'll speak about what we did, and I guess then there are principles that we could apply for people who want to develop something similar in their own setting.

 So, we were fortunate we had funding locally from the university, from a Technology Enabled Learning Project or TELP Grant and the University were keen to work with Cambridge University Press and Assessment, and team led Deirdre Cijffers. We met together and we looked at the work of Professor Karen Forbes at Bristol, who developed a scenario about a decade ago, largely text based. But we did this idea of this branching scenario where choices have implications and initially Professor Forbes is very kind, she said, well, why don't you just update my scenario and you can use it, and then we can share it, and then that would be good. The problem is, is that the underpinning structure of any branching scenario is so fiendishly complicated, that it's actually easier to write a new one than update someone else's.

So, we decided to start from scratch and a group of us Deirdre Cijffers Annabel Price and Anna Spathis, who, you know, from a previous episode or the podcast two members of the palliative care teaching team here. We sat down, we had a focus group for several hours at sort of Cambridge University Press headquarters, and we had lots of post-it notes, and we drew huge diagrams on the walls, and we decided what the narrative arc of the scenario that we wanted to offer. And from that we generated some learning objectives. And then it was a process of, well, how do you turn the learning objectives into this interactive story?

And it starts off with bubble maps. Now, I hadn't come across what a bubble map was before, but it's a drawing. It looks like a sort of an architectural drawing of lots of boxes and arrows. And I wish I could show you what one looks like, but it's extremely complicated. It is like playing 3D chess because every bubble map, every bubble as it were, represents a learning experience or a slide that students experience.

And it's important not to have blind loops. It's important that they don't experience the same thing again. It's important that it makes narrative sense. So, the content has to sort of refract almost the content from every other bit of the scenario, if that makes sense.

[00:07:23] Cheryl: It does.

[00:07:24] Robert: So, it's a very complicated diagram, and then each of those separate little boxes on the diagram represents some bit of content.

So, it may be an actor delivering a bit of speech, it may be a drug prescription choice, it may be a video of something happening with the nurse. But in any event, once you've got the template of what the structure looks like then it's a process of writing it.

[00:07:47] Cheryl: I mean, that's quite interesting.

So, I love the way you started out with, you know, lots of sticky notes and it seems very basic, but you have to start somewhere and then it gets very complex quickly. Yes. And thank you for your description of bubbles and how complex each of those can be because it isn't just a quick, oh, we'll do this and then we'll get it at the end.

So, I think that's really helpful to understanding that. So, this is kind of your, would I be correct, and I don't know if I'm using the right terminology, but this is kind of the start of the story boarding, and you then have to script what you would do for each scenario is that correct.

[00:08:27] Robert: Yes. So, I suppose I'd like to think about it as you develop a story arc of what happens from the patient, from the beginning to the end. What key tasks do we want students to have participated in? And then the process by which they get there is this bubble mapping. It's like a storyboard for a film only that the film can run in lots of different ways.

[00:08:48] Cheryl: Forgive me, I might have the wrong language here. So, help me. Do you then kind of storyboard and write a script or how exactly do you implement these different segments of learning?

[00:09:01] Robert: That's a great question. So, it was very much a steep learning curve.

You know, my background is very much medicine rather than learning, design or architecture. So, it's best thought about, I think of each learning experience is its own segment and each of those segments is then sewn together, depending on what the student chooses. And each segment needs to be represented diagrammatically and then also scripted.

And the script may be content for an actor to speak, or it may be feedback following a decision, or it may be a chest x-ray, or it may be some phone call with a medical registrar. But once the writing bit is done, it's then a case of translating the written text. We ended up with over 200 pages of written text into videos in audio chunks and tables and diagrams and things.

So, I don’t know if you know Alan Orme from Simpatico Medical Role Play. He very kindly played the director of the program, and he hired four actors for us, and he does all of the roleplay supervision for the very extensive clinical communication skills training we have here, at Cambridge. So, he is a very, very experienced man and he very kindly helped the characters get into role, with the content and was present on the two filming days.

So, we mocked up bit of the Deacon Centre here in Cambridge to be a ward environment. We had the nurse in the nursing uniform and the medical registrar at the office and things, and then also we turned Cambridge University Press. Yeah, their sort of sports centre into a ward area as well, just for fun. Bearing in mind all this filming was done during the pandemic.

[00:10:42] Cheryl: Wow.

[00:10:43] Robert: It was all quite difficult to logistically to manage. But yeah, so once we'd done the filming, then it was a matter of editing and then slotting in the various different bits of film into the overall structure.

[00:10:55] Cheryl: You make it sound quite easy, but I'm going to take you back, you said over 200 pages.

[00:11:01] Robert: Yeah.

[00:11:02] Cheryl: Worth of script. I mean, that's quite a lot to fit into two days of filming. So, I think that's really impressive that you were able to manage this.

[00:11:11] Robert: Yes, filming takes a long time. Even just a, you know, a simple segment of an actor talking about their wife can take maybe seven or eight different takes. And so not, I should say that not all of the program is film. So, the film is there to anchor the characters and to give the students the sense that they are the real doctor. But a lot of the content is text where they're given a drug and they're asked to choose a dose or a route and things.

[00:11:37] Cheryl: Okay.

[00:11:38] Robert: Or it may be an audio call, or it may be an arterial blood gas measurement, they need to interpret or whatever. So filming is only a component of creating, the whole arc.

[00:11:47] Cheryl: Which you then said you have to go and edit, which again is not going to be an insignificant task when you've got so much content to weave into that. Because you've said it's not just about the filming, it's about the content of what drug dose are you going to do or here's some results of tests that have come back. There's a lot to put together for that as well.

[00:12:09] Robert: There is, yes. And looking back, I don’t know, you know, I don’t know if I would've done it had I known how much working was going to be.

But it's about 400 hours I reckon of my time for writing.

[00:12:20] Cheryl: Wow.

[00:12:22] Robert: Over a little while. So nevertheless, it was very satisfying to create something that's not been done before. And that gives energy to project and knowing that it's a really important part of medical education. It has an impact.

[00:12:34] Cheryl: Absolutely. So, I think we should say thank you for giving that time and to making such a wonderful resource, but I also think it's really helpful for you to reflect on the time, because I think sometimes, we look at tools. And think, oh wow, that's good. And you don't recognize how much effort goes into developing a learning resource, but how important that is to get it right.

So, I think that's really useful. So, I think we'd say thank you first and foremost for giving that time.

[00:13:04] Robert: Well, that's very kind. I like the idea of doing something new. I like the idea of students being able to access a resource remotely. And if we compare it to say, face-to-face simulation, it's very popular.

 It's actually much cheaper to develop an online multimedia resource than it is to develop face-to-face programs. Because imagine you've got six students in a group with 300 students in a year. You've got to run it every year with lots and lots of facilitators, lots of lots of role players.

Whereas here, the cost is very much upfront. You spend the money and the time to make the thing, and then once it's done, then you can run it for years and years and years at scale. So, we worked out that we spent fourteen and a half thousand pounds on actors and filming and software you know, that sort of stuff. And that works out over five years just here in Cambridge to eight pounds, twenty-nine pence per student to do the resource.

[00:13:59] Cheryl: Wow.

[00:14:01] Robert: And for the amount of learning time, we would normally spend about two-hundred pound per student for that, you know, for an equivalent amount of learning time with a normal sort of face-to-face interaction or lecture or whatever.

[00:14:11] Cheryl: I mean, I think it's important to say that, that interaction's still really important, but as you say, you can't always have that. So, it's good to have a mix of the two and wow, what a difference in resource cost. And I think, again, that's important to bring out because if somebody's interested in thinking about the different learning styles and, and techniques that you could apply, it's good to have a mix and not be afraid of a scary number to start with and recognize that you can do a lot with that.

[00:14:42] Robert: Yes. So, to be a hundred percent clear, I really don't think that multimedia simulation should replace large parts of balanced medical curriculum. I mean, the primary thing is that students have an apprenticeship of learning how to be a doctor with time with experienced clinicians and seeing lots of patients as well as having deductive content.

I suppose the thing that multimedia simulation allows us to do is give students learning experiences that they otherwise wouldn't get because you're not allowed to prescribe insulin as a student. You're not allowed to have a breaking bad news conversation as a student. Whereas you can do that with the multimedia simulation, so students are not sort of thrown in at the deep end when they graduate. They've already had a bit of a trial run.

[00:15:22] Cheryl: Absolutely, and you know, I totally agree with you. We can't replace, but this is a very specific training tool for something a student can't do otherwise. Yeah. And I think that's really helpful and useful for students to have that opportunity to make mistakes in a safe environment, as it were. To go down the scenarios in maybe a way that we wouldn't want them to do in real life. Equally if they go down a scenario that is appropriate, it helps them to give some confidence of, okay, I am making the correct decision for this patient.

[00:16:00] Robert: Absolutely. Because we know that making mistakes in a really safe way is one of the most powerful drivers for long-term retention of learning.

Because once the patient has given a drug that causes the patient's Parkinson's disease to get worse, they won't do that again because they've had the experience of making the choice and then seeing what awful things happen and the distress that it causes, and it really gets lodged in the memory. Like, oh, I will not do that when I actually come to practice.

[00:16:27] Cheryl: Absolutely.

[00:16:28] Robert: And the way the learning segments are designed is that there's a choice, followed by seeing the outcome of the choice, followed by feedback of what the best choice would've been and why the choice they might have made, is not quite right.

[00:16:39] Cheryl: Okay. That's quite helpful. I mean, I think it might be helpful, as we've talked about the fact that there is this tool. Would it be useful to just kind of go through what components there are in the tool? So, it would help, I think, give our listeners a bit of a better understanding.

So, there's four sections. So, we've got patient assessment, rationalizing medication, prescribing symptom control medication, and clinically assisted hydration. Can you walk us through those steps in a little bit more depth?

[00:17:10] Robert: Yes. Thank you. So, the first section is where the F1 doctor, this junior doctor, meets our patient and their husband, as well as the other characters, the medical registrar and a nurse.

And they are given the history of what's happened to the patient, and then they're given various options about how they wish to proceed when assessing them. The idea is it's a very busy hospital day and they're just sort of thrown in and they have to make up their mind about how long the patient has left to live. They need to interpret a series of investigations, decide whether or not to put in an intravenous cannula. Turns out that that's actually very difficult for this particular lady in the various choices that they have to make as a result of that. And then once they come to the end of that, it's clear that the patient is dying.

And then that leads on to the next section, which involves rationalizing drugs. So rationalizing drugs is a decision-making process. It doesn't get much medical training airtime, but it's quite important for when a patient can't swallow their medicines anymore. What medicines to really prioritize them to have how to give them in any, any sort of other ways. And in that sort of second section, we’ve got the importance of spiritual care and where that fits in in looking after a patient who's dying.

Third section is about prescribing for symptom control. So, this, these are so-called anticipatory medications as well as making a plan for how to manage bowel and bladder function.

And then the final bit is really mainly a communication skills session. So, the husband wishes the patient to have assisted hydration, so a drip even though she can't drink and the evidence that we have doesn't really support that being a routine practice, and yet he feels very strongly about it. So, there's a back-and-forth decision-making process together of how to come to some mutually agreeable plan.

There's a management of secretions, so just secretions later on in that segment. And then really importantly, it finishes on a very affirming end, there's a lot of gratitude expressed, and that makes the process psychologically safer, and I think more rewarding as a result because the students by that point will have had fair amount of negative feedback.

 So as a whole, it feels nice. It feels good. It feels like it's an important thing to be doing.

[00:19:23] Cheryl: Thank you. That's really helpful to talk us through that. And I think it was useful too for you to explain that there are different scenarios in there and there are some options for negotiation and the importance of speaking to the family as much as the patient because sometimes the patient isn't as aware of what's going on. But that family connection, you need to be able to manage that as a junior doctor as well and or any stage of being a doctor, and I think that's really important to say that that's been brought out as well. And it does end on a positive note. Even though we're dealing with a very sad situation, it's useful to understand that the right decisions will help those that are left behind.

[00:20:06] Robert: Yes. Thank you. That's a really, important point actually, that how we look after dying patients is important for them and it's also important for their families and the memories that they have of that time. And when we think further on about our own deaths, our experience of death with our relatives, sort of patterns, how we might imagine our own futures.

And so, from a societal perspective, how we experienced death is extremely important. And medicine is not the whole part, but it is important when people are suffering horribly at the end of life. And there's so much that can be done to make things better, more dignified, more person-centred, even when a patient can't express what they would've wanted.

[00:20:47] Cheryl: Absolutely. Thank you for that. I think that's one thing we really want to highlight is that it doesn't have to be a horrible scenario. It's about making sure that we have trained doctors to make it the best it can be at that time. So, thank you for that.

I'll go back to the tool again and just say, I understand this is relatively new. Have you had much feedback so far on how junior doctors or medical students are interacting with the tool?

[00:21:17] Robert: Yes, we've, we've run it three times here in Cambridge once in Norwich Medical School, and there are ten other medical schools in the UK that are at the moment looking at it and deciding whether or not they wish to use it in their own settings.

But here in Cambridge, we've had some great feedback. People have said that it's what the best resource they've experienced in their medical training to date, which is very gratifying. They say it's very immersive. They find it emotionally moving. Several students, they said they love more of these in for other subjects, you know, cardiology or whatever it is.

And the overall feeling really is that students like being able to learn from mistakes. They like being in the decision seat. They don't always have to be passive recipients of content from others prior to graduation that they can be a doctor before they're a doctor and they, yeah, they really give that feedback.

Numbers wise, 92% or so felt more confident as a result of doing the training in managing dying patients, which is good news. 8% felt less confident.

[00:22:19] Cheryl: Ooh.

[00:22:20] Robert: In the earlier versions, at least.

[00:22:21] Cheryl: Okay.

[00:22:22] Robert: And about a third felt quite stressed doing it because it's high stakes. Because it is emotionally moving. It does feel important. They are engrossed in the role and in the characters, which tells us that it's a powerful way of training someone if you can get their emotions engaged. But it does mean that we've had to iteratively reduce how hard the scenario is. So, we're now on version three. It's a gentler ride, an easier ask now than it was when it was first fairly stressful.

[00:22:52] Cheryl: That's, I think that's fantastic. You're right. You have to get that feedback to understand that, oh, okay, maybe we are a bit too harsh. But it's good to know that the vast majority were more confident based on having gone through this scenario of training.

And again, it's in that safe environment and in an area that they wouldn't otherwise be able to train.

And I wonder too, it's just listening to you talk about some of this. They're not being assessed on this, so students can do this anonymously at home or wherever in a comfortable environment where they're not feeling like somebody's watching over them. And if they get it wrong, they're in trouble, as it were, not in trouble, but you know, the stakes are higher.

Does that have an impact on how students feel? Looking at this sort of scenario,

[00:23:42] Robert: Yes, I think it does. I notice when teaching larger groups of students, there are some students will always be quiet and won't participate for fear of getting the answer wrong or sort of somehow feeling experience or sort of social shame. And that sort of peer group perception is quite a powerful force at medical school for many, many of our medical student colleagues. So doing it in the privacy of one's home, home makes it, firstly, very consistent; every student is going to have the same experience and every student will engage equally because they can't be quiet and sit at the back. They have to be the doctor because the choices keep presenting themselves, the clinical decisions.

And we've structured it so that breaks are encouraged. Self-care is encouraged. Self-compassion is encouraged. So being able to do that in chunks you know, or in one go, which whichever works for the student. I think is one of the popular things about it.

[00:24:38] Cheryl: Absolutely, and I'm glad that you mentioned the importance of self-care and taking breaks, because that does come across, you know, this is a lot to get through. Take a break, go get a cup of tea, whatever.

I actually did the course, and I followed a couple of scenarios just to see what happens, and it was like, oh, okay. Yeah, you're right. I have been sitting here for a while. Take a break. You know, we don't always do that. And it is quite an emotional topic to be thinking about, so it's nice to think, okay, right. Take a break, come back. Are you clear with your thoughts? Potentially. And that's true in real life. Sometimes we do need to say, I'll be right back.

[00:25:15] Robert: Yes, and absolutely. And part of the scenario is also encouraging students to model the behaviour that they want to, or we want to engender in our medical community following graduation is that we want doctors to look after themselves.

We want them to be emotionally open. We want them to be well resourced. We want them to be rested. And that self-compassion piece and care is one of the things that we hope to train people using the scenario.

[00:25:43] Cheryl: Yes. And that did come across. So, I think that's useful to have pointed out.

This has been really interesting. Thank you so much for chatting with us today and telling us more about this whole process and the program that you've developed.

What would be your main takeaway points for listeners today?

[00:26:02] Robert: Very interesting question. Thank you. Firstly, the potential of multimedia simulation. Any professional experience can be simulated. Any minoritized patient group, any hard-to-reach group can be simulated and the, yeah, just the potential is vast. Secondly, it's a really popular methodology for students. They really like it. And thirdly, it's extremely cost-effective way of delivering consistent training across a large group of medical students.

And before I say anything else, I just wanted to say thank you to several people who've been involved in this project. It's one of the things that I've heard said often is that if you want to go quickly, go alone. And if you want to go far, go together. And this is very much a large team project. I think 30 odd people have been involved in the creation of editing, of acting, of trialling it. You know, it's been a big project and particularly I wanted to thank Professor Stephen Barclay and William Mair, Senior Educational Technologist here in Cambridge, who both initially managed to secure the Technology Enabled Learning Project Grant. And William, of course, has been very involved in actually making the script and the videos hang together using all the software. So, he's been really pivotal Deirdre Cijffers from Cambridge University Press Assessment and her team Annabel Price and Anna Spathis as I mentioned previously.

And yeah, thank you for having me. It's really a real pleasure to be able to speak about our work.

[00:27:38] Cheryl: I want to say thank you because I think your three takeaway points really tell us exactly how important this sort of training method is. And it's great that students really like it as well. And it is a great learning resource.

So, thank you very much for talking with me today and for being a part of this podcast. So, Dr. Brodrick, thank you once again for such an interesting discussion.

End of Life Care is a difficult topic to cover. And ensuring our doctors are ready to deal with end-of-life care in a sensitive way is important for not only the patients but the families as well. So, you've really helped to give a tool that we can use. So, this simulated managing dying course provides an insight into how to approach such a difficult topic and some of the positive and negative responses that may come from family members.

If listeners are interested in learning more about this excellent simulation course, please contact us via the CUMEG website at www.cumeg.cam.ac.uk.

We'll have further information about how you can review this free resource and provide you with an opportunity to discover if this is something that your hospital or university could benefit from using.

We are grateful to you, our listeners. Thank you for taking the time out of your busy schedules to listen to us today.

If you would like to hear more from this or our previous podcast series, please like and subscribe to our podcast.

Until next time, I'm your host, Cheryl France. Thank you once again for listening.