Intended for healthcare professionals

Rapid response to:


Face masks for the public during the covid-19 crisis

BMJ 2020; 369 doi: (Published 09 April 2020) Cite this as: BMJ 2020;369:m1435

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Rapid Response:

Competency assessment in an era of masked health professional examinees

Dear Editor,
In a prescient piece published in BMJ on April 9, 2020, Professor Greenlaugh et al argued for policy recommending masks for the general public to prevent the transmission of COVID-19 [1]. Since that time, the body of literature, and government endorsement within various international jurisdictions, has caught up to this point of view [2]. As we begin to emerge from various states of isolation and physical distancing, with the shadow of second waves ever present, we can anticipate that masks will now remain an integral part of our lives throughout the world. Widespread donning of masks will impact how we function and move through many facets of society, not least of which how healthcare is accessed (as patient) and delivered (as provider). Such protective measures necessary to sustain public safety have specific implications for health professional education.

The OSCE or objective structured clinical exam model is used by health disciplines to test clinical skills, knowledge, and performance [3]. Examinees proceed through a series of stations (usually small physical spaces) interacting with a patient actor or examiner (in relative close proximity) for approximately 10 minutes each. While most stations require direct communication between individuals, some encounters also include a clinical examination. The OSCE is an assessment modality deployed within various health professional curriculum, as well as by professional licensing bodies globally …and these have been summarily suspended in the face of COVID-19. Certainly, a number of programs have pivoted to skills assessment online just as patient care delivery through virtual platforms has escalated in these past months. However, given the advantages of high-fidelity situations for standardized assessment of direct patient care, and practical limitations to simulating aspects of healthcare that must be conducted in person, it is highly likely OSCEs will resume in some form in the future. These conditions will assuredly entail physical distancing and masks to ensure the safety of participants. As our faces are central to both verbal and non-verbal communication in person-centred care–the empathetic tone, a reassuring expression or understanding smile - how will we judge trainees now?

Conducting health professional competency assessment in settings where full facial expressions are obscured is in fact not new. Examples of OSCEs in regions where cultural dress covers partial or full views of the face exist and may provide guidance for assessing communication skills elsewhere. Evidence suggests that examiners from diverse cultural backgrounds can adapt to environments where an individual without full facial exposure engages patients, but the assessment instruments require refinement to accurately rate this performance [4]. Instead of deconstructing communication into individual components, for example, tools should instead target more global constructs such as confidence, development of rapport, and adaptability. Examiners will also need guidance on how to reconcile traditional perspectives of what behaviours constitute competent communication with those now required for practice in the post-COVID era. Moving forward, health professional programs must attend to the development of such expanded skillset among trainees (e.g. greater emphasis on eyes and voice), as well as to the re-orientation of examiners adjusting to altered communication norms between patients and practitioners wearing personal protective equipment. Revising scoring tools to encompass more holistic assessment of competent communication may be a starting point to ensure robust assessment of professional performance [5].

1. Greenhalgh T, Schmid MB, Czypionka T, et al. Face masks for the public during the covid-19 crisis. Bmj 2020;369:m1435. doi: 10.1136/bmj.m1435 [published Online First: 2020/04/11]
2. Chu DK, Akl EA, Duda S, Solo K, et al. Physical distancing, face masks, and eye protection to prevent person-to-person transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis. The Lancet 2020; [published Online First: 2020/06/01]
3. Harden RT, Stevenson M, Downie WW, Wilson GM. Assessment of clinical competence using objective structured examination. Br Med J 1975;1(5955):447–451.
4. Wilby KJ, Diab M. Key challenges for implementing a Canadian-based objective structured clinical examination (OSCE) in a Middle Eastern context. Can Med Educ J. 2016;7(3):e4-9.
5. Wilby KJ, Govaerts M, Austin Z, Dolmans D. Discriminating features of narrative evaluations of communication skills during an OSCE. Teach Learn Med 2019;31(3):298-306

Competing interests: No competing interests

22 June 2020
Kerry Wilbur
Health Professional Educator
Kyle J. Wilby (School of Pharmacy, University of Otago -
Faculty of Pharmaceutical Sciences, the University of British Columbia
Vancouver, BC Canada