Andrew Burd: “Are you sure?”

It is that time of year again. May heralds the last few weeks of the medical curriculum, culminating in the final examinations. Over the years at the Chinese University I have seen the examinations become increasingly sophisticated from the perspective of objective educational assessment. It took a critical event – namely, SARS – to cause a radical change in the format of the examinations.

The OSCE stations have become an opportunity to incorporate increasingly realistic clinical scenarios for the students. To put some context in place I should mention that every fifth year medical student at CUHK spends a structured week of teaching in the division of plastic reconstructive and aesthetic surgery. Being the only surgical team involved in the gigantic integumentary system we have much to share but try to focus on what is practical and most useful for the generic doctor.  To this end in addition to our structured clinical teaching each group of four students spends a day working with the nurses on the burn unit.  The medical students are told this is as much a test of their initiative as it is a formal educational experience.  They are told to offer to help the nurses perform wound dressings and to ask questions. I tell our students this because I know that our nurses are excellent but I do not want the medical students to be “spoon fed.”  I tell our final year students that their quality of survival in their first year as professional doctors will depend far more on the relationship they have with their nursing colleagues than with their medical peers and seniors. The interns who do not do well are those who are arrogant or lazy and do not genuinely care about patients.  Such doctors can be sifted out by the nursing radar and in a host of subtle ways be subject to reprogramming techniques. 

To instil inter-professional respect at the student stage is good. So this year we thought to try something new. We developed an OSCE station run by our nurses. There was one experienced nurse specialist who acted as examiner and two student nurses, one was the surrogate patient with a wound; the other student nurse waited to receive instructions from the ‘doctor’ who was tasked with assessing the wound and deciding on the most appropriate dressing regime.  To make the choice easy, four dressings were on display and the medical student was asked to choose one.  In our final practice run as we set up the logistics of the OSCE we decided to add a question after the student had made their choice of dressing. The specialist nurse, who was also the examiner, asked the student, “Are you sure?” This is a simple station testing aseptic technique, doctor-patient and inter-professional communication, assessment of a wonderfully realistic “moulaged” wound and the management of that wound.  But so far, without exception every student asked that question by the experienced nurse has changed their choice of dressing! There has to be difference between arrogance and confidence, but also between guessing and knowledge. We had anticipated this during our teaching; and repeatedly instructed the students, “if you are not sure ask our experienced nurse what they would suggest.” I will talk more about the concept of “face” in Chinese culture, but certainly in the practice of everyday medicine we must ensure that our new medical professionals can work with our nursing staff in a spirit of common concern for patient welfare. Status or hierarchy cannot come in the way of appropriate care. So if you are not sure; ask. To be honest and humble is the sure way for the new doctor to gain the respect of the nursing colleagues. Of  that I am sure.

Andrew Burd is professor of plastic, reconstructive and aesthetic surgery at the Chinese University of Hong Kong. His major clinical interests involve paediatric burns care and the role of plastic surgery in the palliation of advanced malignancy. Academic interests include pragmatic ethics related to the practice of medicine including research and publication.