Examining for bedside manner

'Patients' played by actors assess clinical skills of medical students

Health & Fitness

August 11, 2002|By Aparna Surendran | Aparna Surendran,PHILADELPHIA INQUIRER

Martin Williams, the 17-year-old captain of his high school basketball team, is sitting in the doctor's office complaining of a constant headache.

In reality, the "patient" is Matt Saunders, 25, an actor and set designer. The doctor, though, is real: Shahram Sani works at Abington Memorial Hospital near Philadelphia.

This little exercise is designed to test his bedside manner.

Technically, the "clinical skills assessment" measures the ability to gather information, perform physical examinations and effectively communicate with patients. A big part of it is how comfortable the doctor makes patients feel -- the intangible known as bedside manner, something that many doctors in recent years have been accused of lacking. Indeed, it is sometimes cited as a reason that Americans are turning to alternative therapies by the millions.

The test is required for graduates of foreign medical schools seeking licenses to practice in the United States. Now, the National Board of Medical Examiners is looking to make it a requirement for third- or fourth-year U.S. medical students as well.

The test cannot be standardized because each patient is unique. Instead, it uses what is known in medical terms as a "standardized patient," an actor paid to ask a set of questions depending on his or her malady.

Because the boards that oversee testing for both sets of students are located in Philadel-phia, the pilot program is working with three medical schools there: the University of Pennsyl-vania, Temple University and Thomas Jefferson University.

The test would have medical students see 10 "patients," for 15 minutes each. The "patient" would score the encounter on a checklist of all the questions the doctor should ask, said Gerald Whelan, who runs the program for the Educational Commission for Foreign Medical Graduates. The medical students will also write notes on the patients' complaints, the findings of their physical examinations and their diagnoses.

"Each of these scores are averaged over 10 cases," said Peter Scoles, a senior vice president of the National Board of Medical Examiners. Doctors at the national board will compare the student's notes and the patients' checklists and give a final score.

Graduates of foreign medical schools were required to take the test beginning in 1998. Last year, about 7,200 took the exam; about 20 percent failed the first time, Whelan said.

The National Board of Medical Examiners expects about 1 percent to 2 percent to fail the exam on repeated attempts. The exam may be taken as many times as desired.

The board plans to expand its Philadelphia pilot to Atlanta in the fall. If that goes well, it hopes to add the test to the national licensing exam in 2004.

Although medical licenses are issued by individual states, all state medical boards require doctors to pass the national licensing exam.

"Some medical students have exceptional cognitive skills," said George Van Komen, past president of the Federation of State Medical Boards. "They are able to repeat information and have the ability to take the data and use it appropriately, but they lack the ability to appropriately communicate and examine patients."

The test was part of the licensing requirement until 1964, a time when many patients were happier with their doctors' bedside manner. It was dropped due to questions of fairness and reliability, Scoles said. He says those issues have been resolved.

Not everyone supports the examiners' plan. Both the American Medical Association and the American Association of Medical Colleges have raised objections, largely over funding.

Students would have to pay about $950 to take the exam, and would have to use their own transportation to get to the five to seven sites around the country where it would be offered.

Those arrangements "would place a large additional financial burden on students already reeling under historic debt loads," Jordan Cohen, president of the association of medical colleges, wrote to the board of medical examiners.

Assessing a doctor's clinical skills using "standardized patients" is not new. Most American medical schools include some sort of skills assessment as part of their curricula.

Clinical skills are "absolutely vital," said Mark Swartz, director of Mount Sinai's Morchand Center for Clinical Competence, in New York. "Eighty-five percent of all malpractice cases in the U.S. are based on communication, not medical negligence," he said. But, he added, "to mount this program on a national level is an enormous task."

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