Fight or flight

Abstract

The role of the sense of smell in human communication has been debated for many years.1 Apparently, our bodily odours are involved in attracting us towards the most suitable mates while repelling us from genetic mismatches. In an interesting study undertaken almost 10 years ago, Austrian researchers showed that blinded volunteers could differentiate between the axillary scents of people who had just watched a horror movie versus those who had watched something bland.2 The rank stench of fear is easily identifiable. All of which does have something to do with clinical teaching. That smell assailed me yesterday as I walked down a long corridor lined by medical students waiting to go into their first clinical examination stations. Not that it was the first OSCE (objective structured clinical examination) these students had ever undertaken, nor was it a particularly high-stakes assessment: just one history station and a mini mental state exam in the third year of their course. The stench of fear was undeniable, however, and very different to the usual odours that permeate the crowded corridors of our medical school. Fear is a powerful motivator for survival, but how much fear can be generated by a clinical assessment before the candidate’s performance begins to suffer? Most clinical teachers will recall students who have performed exceptionally well in the clinical context, but who have fallen apart in the simulated setting of the exam room. Part of the skill of the clinical teacher is to create a supportive environment within which the student is able to do their best. Although ‘grace under pressure’ is clearly a desirable attribute of the competent clinician, it is hard to extrapolate surviving the stresses of the exam room to good patient care. Assessment techniques such as direct observation and the mini-CEX (mini clinical examination), which are more grounded in the reality of the workplace, seem better suited to measuring competence rather than performance under pressure. If students perform poorly when excessively challenged, it is likely that their clinical teachers will do the same. It is an interesting time to be a clinical teacher. Global workforce shortages have driven increases in medical school numbers, with unprecedented demands for clinical placements.3-5 Inevitably, this flood of new students washes up at the clinical teacher’s door to be properly prepared for practice. Equally inevitably, a medical workforce shortage means that clinicians are under enormous pressure to increase their patient throughput, and so they are frustrated in their efforts to teach.6 In Australia, at least, the government has begun to understand the ‘three-legged stool’ that supports a student’s clinical teaching: a patient, a teacher and somewhere for the learning to occur. Money has become available through the federal government for teaching spaces to be added to non-traditional clinical teaching sites (such as private clinics and aged care facilities), and more is coming to support teacher training and simulation facilities. The aim is to increase clinical teaching capacity to deal with the extra students entering the system,7 but there is no clear vision of funding reform to ensure the adequate payment of clinical teachers to sustain these new placements. Without clinical teachers being adequately recompensed for the time they spend teaching – and without clinical teaching being recognised as a vital professional activity – we run the risk of having students neglected while their teachers deal with burdensome clinical loads. There is a worldwide need for funding bodies to rank clinical teaching alongside clinical service as equally vital. After all, the provision of clinical services depends on a sustainable supply of students who know what to do. Editor in Chief