Andrew Burd on medical student assessment

Andrew BurdLast weekend the medical faculty of the Chinese University of Hong Kong had its annual curriculum retreat.  This is an opportunity to discuss the ever increasing challenges of teaching medicine in a rapidly changing world.  I was asked to give a very short presentation about the OSCE station we had organised where for the first time in the history of the medical school, senior nurses examined the performance of the medical students in an authentic clinical scenario.  As I was preparing for my talk I reviewed some video clips that were taken of the actual examination.  It was apparent that our students did not expect to see a real patient with a burn and yet once they had a glimpse of the very realistic moulaged burn their attitude changed.  The “burn” was wrapped in a green sterile towel and it was covered with a moistened gauze.  It just so happened that two of the clips showed two students, both now fully qualified doctors, who demonstrated a dramatically opposite technique for removing the sterile gauze.  One student demonstrated the ultimate empathetic approach, “feel the pain” and removed the gauze with breath-taking concern. 15 seconds.  Another student having established that it was a real burn and that it was painful, correctly picked up the sterile gauze with the dressing forceps but then in the blink of an eye the gauze was removed.  Less than one second.

I could not stop thinking about these two very different approaches to a very realistic clinical scenario.  What is the significance of this observation?  I made some informal enquiries of non-medical friends and posed the “hypothetical” question; “if you had a wound on your arm and the doctor needed to remove a dressing to examine it, would you rather the doctor removed the dressing slowly or quickly.” Next surprise; it was almost a fifty-fifty split.

I know from primary school days when having vaccinations that the most effective school nurse was rapid in her technique but wonderfully encourging in her smile and compliments of bravery.  For vaccinations, “hit the arm before they know what is going on” is effective. Removing dressings can be rather different. I am sure the scenario of the child who insists on removing their own dressing and takes an agony of age to do so is not unfamiliar to many of us.

But what was being observed and not assessed in these students?  Is it humanity, compassion, professionalism or just an aspect of personality?  Maybe this is something we should be looking at in more detail, but it will need to be dressed up in more erudite pedagogical terms rather than a study of quick and slow dressing removal amongst final year medical students. Perhaps something like; an analysis of the impact of anticipatory pain on the procedural dynamics of routine wound care in final year medical students.  Or has that already been done?

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.