Virtual Ward Round Teaching Pilot - A new education method.

Final year medical students at King’s College London undergo an 8-week module to enable transition to Foundation Year 1 (FY1). New graduates often cite ward rounds as a challenge and we undertook this pilot to enhance skills not formally incorporated into the curriculum. A teaching session simulating a ward round for nal year medical students was piloted at Tunbridge Wells Hospital. Two-hour teaching sessions were facilitated by medical trainees on a one-to-one basis, where students would see several real patients under direct supervision and conduct a simulated ward round. Facilitators gave feedback on students’ consultation skills after the session.


METHODS
Two-hour teaching sessions were facilitated by medical trainees on a one-to-one basis, where students would see several real patients under direct supervision and conduct a simulated ward round. Facilitators gave feedback on students' consultation skills after the session.

RESULTS
Quantitative feedback from students was 97% positive overall, and comments showed that students felt the session increased their con dence. Facilitators agreed that the session was good way to help the transition to becoming a real doctor and found it bene cial to get teaching experience themselves. CONCLUSION Ward rounds are an integral part of daily life as a new doctor. However, previous studies have shown that nal-year students lack ward round skills, and that this can be improved by simulation. This pilot shows that it is feasible and cost-effective to simulate a ward round involving real patients and thereby preparing students to step up when the time comes.

Background
On ward rounds, newly quali ed doctors (in the United Kingdom termed as Foundation Year One or FY1 doctors) are expected to communicate effectively with patients and colleagues, review and present notes and investigations, properly document entries, and prioritise large numbers of jobs 1 . Medical students are often taught these skills in isolation, and according to the General Medical Council (GMC) Preparedness Survey Report 2014, FY1 doctors feel underprepared for combining these skills in a clinical setting 2 . Since September 2019, King's College London (KCL) have been working on a simulated ward round module for the nal year medical curriculum. The module was piloted during students' transition to FY1 (TTF1) rotation at Tunbridge Wells Hospital from January to February 2020. TTF1 is an eight-week placement at the end of the nal year designed to bridge the gap between the nal year of medical school and the start of clinical practice as an FY1.

Method
Ethics approval was not deemed necessary according to the National Health Service Research Ethics Committee. Institutional ethical clearance from King's College London was also not required, as the teaching sessions formed part of an existing taught course module for which there was already the requisite ethical clearance.
In total, seven nal-year students and ve facilitators participated in the pilot. The sessions ran twice per week during the TTF1 period (January to March 2020) in the medical wards of Tunbridge Wells Hospital, with one Internal Medical Trainee (IMT) doctor facilitator and one student per session. Sessions lasted two hours and ran from approximately 17:00-19:00 on weekday evenings.
Before each session, the facilitator identi ed two to three suitable patients and obtained consent from them. A patient was suitable if they met the following criteria: not medically t for discharge; well enough to see and able to communicate; admitted for less than 3 days with an uncomplicated history.
We provided a session structure to facilitators, although it was not prescriptive. Facilitators were encouraged to tailor the format relevant to the patients they had found. The advised session structure was as follows: read through patient notes; review investigations done during current admission; carry out the ward round under direct supervision and perform a relevant focused examination; review prescription chart, and other charts as appropriate, e.g. capillary blood glucose, uid, stool, food; chase outstanding jobs and investigations from previous ward round entries; generate and prioritise a jobs list; prepare the patient's discharge letter; make necessary referrals or request investigations by practicing with students; identifying deteriorating patients and knowing when to escalate to seniors or other healthcare professionals; discuss ceiling of escalation; document the ward round using the hospital continuation sheet; handing over outstanding jobs to out-of-hours medical team; debrief & give feedback to student.
Facilitators were encouraged to give feedback on the consultation and clinical skills of the student, the quality of their documentation, and on the jobs list they produced. This was done by comparing the students' ward round entry to the entry done by the parent team of the patient that day, and ensuring they are up to the standards set up by the Royal College of Physicians (RCP). The RCP states that "Every entry should have a time, date and identi able author… Multidisciplinary notes should be used for … recording progress reports and noting down any questions relating to patients' care. Discussions with patients, carers or relatives should also be centrally documented…" 3

Results
All seven students and ve facilitators completed a survey containing multiple-choice and open answer questions at the end of the TTF1 rotation. All the multiple-choice questions were worded as statements, with respondents asked to rate to what extent they agreed with the statement. 1 indicated "strongly disagree", 2 indicated "disagree", 3 indicated "neutral", 4 indicated "agree" and 5 indicated "strongly agree". Student feedback was 97% positive (percentage of answers "agree" / "strongly agree" given), and by the same metric, facilitator feedback was 93% positive. The timing and the duration of the sessions on weekday evenings suited most students and facilitators, with room for swaps to be arranged if they were unable to attend.
Students particularly relished the one-to-one teaching structure, and the opportunity for immediate feedback tailored speci c to them. Some have found that it was a better experience overall to be able to practice in a supervised and safe setting instead of having to do a real ward round unprepared. They reported that the session could be improved by adding a separate decision-making exercise, and focusing more on escalating to seniors, a remark echoed by facilitators. One student commented that escalating to seniors is something they feel is not covered in the current curriculum, so it may be that students felt less con dent in this task compared to other skills covered in the session.
Facilitators valued the scheduled teaching experience in a one-to-one setting and commented that the session was helpful for nal year medical students in transitioning to FY1 doctors.

Discussion
Students broadly agreed that this teaching met their learning objectives, although they reported being less con dent than in other tasks such as prioritising a list of jobs and escalating to seniors. To improve the quality of the feedback, a pre-session questionnaire asking the same closed questions would show a baseline level of students' con dence in ward round skills to compare with the post-session feedback.
Engagement with the sessions was good, with students and facilitators rating each other's contributions highly. One comment from a facilitator suggested expanding the session to include several students each doing a different part of the ward round -however, most students stated that they enjoyed the opportunity for 1-on-1 teaching and feedback.
One potential advantage of this format of ward round simulation is that it does not require high-delity simulation equipment or a dedicated simulation suite, which are costly and require trained staff to maintain. By using real patients and junior doctors working on the same wards the sessions were based on, this pilot was simple and cost-effective to set up, and could easily be scaled out into any hospital specialty or setting.
Ward round tasks such as presenting patients, interpreting investigations and summarising medical notes require FY1 doctors to process large amounts of text and memorise large sets of gures and results. This may present a challenge to some students with neurodiversity such as dyslexia or dyscalculia. Dyslexia is present in up to 2% of medical students. [4][5][6][7] By implementing ward round simulation, it may be possible for those students with dyslexia to identify ward round skills as a particular challenge prior to starting FY1. Students could then liaise with occupational health and student support in medical school or use the Supporting Trainees Entering Practice system to get support for these speci c issues before they become a source of stress for trainees in the workplace. Identi ed challenges in learning can then be communicated to foundation schools to enable optimum support of FY1s.

Conclusion
Simulated ward rounds enable students to combine clinical, communication, and organisational skills in a realistic setting, and previous studies have shown that ward round skills can be improved by simulation [8][9][10] . This pilot shows that it is feasible and cost-effective to simulate a ward round involving real patients and thereby better prepare students for future practice.

Next steps
To improve upon this pilot in the next cohort of students, we intend to introduce a standardised sheet to use to document the simulated ward round. We hope that this would be freely available to download from the university's online portal known as King's E-learning and Teaching Services (KEATS) or a similarly accessible location. This would increase the delity of the simulated ward round and give students something to take away and compare to real-world examples to improve their documentation skills.
Longer term, we would like to involve the multidisciplinary team in this simulation to enhance skills in team working and communication.
One student commented that the teaching could be improved by having a talk on ward rounds as a cohort before the individual sessions take place. To help standardise the sessions across sites and remove the need for room bookings and scheduling, we will be uploading a video on this session to KEATS for students to access prior to the sessions, which includes useful tips and tricks. Ethics approval was deemed unnecessary by the National Health Service Research Ethics Committee review. Verbal consent was taken from participants. The study did not involve any identi able data collection, tissue/organ retention, involvement of any vulnerable individuals, or use of medicinal products. Ethical approval was not required from King's College London as the teaching sessions were part of an existing taught course module for which there was already ethical clearance.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.