An old maxim says there's only one thing worse than being given bad news, and that's hearing it from someone who's happy to deliver it.
That sage expression apparently escaped the knowledge acquired by a medical student, who undertook a new kind of licensing exam. It's designed to gauge communication skills, not just information-carrying capacity.
Not only did this young doctor tell the patient he suspected metastatic cancer, he seemed completely indifferent to the fact he'd just issued a diagnosis the patient considered a death sentence.
“Research shows that a small but significant number of students who pass multiple-choice exams lack the basic clinical and communication skills necessary to practice medicine.”
National Board of Medical Examiners Report
As a result, he flunked the test, and deservedly so, said Gerald Whelan, MD, an emergency physician who's been involved with the effort to implement this new addition to the current United States Medical Licensing Examination.
Why is it needed? Because, as this young physician illustrated, it isn't enough to be a brilliant doctor who can fly through the written portion of the boards.
Medicine needs good communicators, Dr. Whelan said. Poor communication and interpersonal skills are related to a higher incidence of malpractice suits and of lower treatment compliance by patients, not to mention decreased patient satisfaction.
“The best multiple-choice examinations cannot adequately assess clinical and communication skills. Research shows that a small but significant number of students who pass multiple-choice exams lack the basic clinical and communication skills necessary to practice medicine,” according to a report in support of the new test by the National Board of Medical Examiners (NBME), which officially approved the addition along with the Board of Directors of the Federation of State Medical Boards. “The roll-out is 2004,” Dr. Whelan noted.
Estimates so far indicate that about seven percent of the medical students in the United States won't pass this new form of examination on their first attempt. In fact, it probably will prevent 250 to 500 students from receiving a medical license each year, according to the NBME. The cancer-diagnosing young doctor would be one of them, at least temporarily, Dr. Whelan said. “He didn't seem to know how insensitive” he appeared to be. As a result, this was one future specialist who had to undergo a little retraining, said Dr. Whelan, the vice president of clinical skills assessment for the Educational Commission for Foreign Medical Graduates.
The new examination will prevent 250 to 500 students from receiving a medical license each year
Dr. Whelan said emergency physicians for the most part will do well on such an exam. It is so clearly reminiscent of the very attributes that skilled emergency physicians possess: quick processing, the ability to elicit needed information, and the kind of approach to patients that allows them to believe they're in the presence of a nonjudgmental authority.
Patient Care Context
The assessment has been for the past several years part of a pilot program for evaluating clinical skills. It is being called a test of bedside manner in the popular press, a term that Peter Scoles, MD, a senior vice president for the National Board of Medical Examiners, doesn't much like. He pointed out that the new test encompasses far more than a look at personal interactions with patients. It's actually a bit of very realistic clinical mimicry. “Our examination tests communication and information-gathering ability. Physicians have to know things, but they have to be able to use them in the context of patient care,” he said.
“The days of the ‘cowboy surgeon’ are over.”
Dr. Gerald Whelan
Carefully trained testers pose as patients, who present with different diseases and conditions. The cases cover common situations a physician is likely to encounter in a general ambulatory clinic, or as Dr. Whelan puts it, an urgent care situation. These pretender-patients come from a broad range of age, racial, and ethnic backgrounds.
The assessment is designed to mirror a physician's typical workday: For about 15 minutes each, students are examined by means of 10 such ringers, who are referred to more technically as standardized patients. The test-takers are expected to establish rapport with them, to obtain pertinent historical information from them, and to perform the necessary physical exams on them, as well as provide counseling and advice.
After each standardized patient, students have 10 minutes to record pertinent history and physical examination findings, list diagnostic impressions, and outline plans for further evaluation if necessary.
Time to Get Tough
The concept of such a test isn't all that new. The American Association of Medical Colleges issued guidelines three years ago, but only about half of all American medical schools routinely evaluate students' clinical skills with standardized patients, and only about a quarter require students to pass such tests for promotion or graduation. Anecdotal observation by faculty and residents remains the main method of evaluating clinical skills at nearly all medical schools.
So the time was ripe to get tougher in this assessment area, Dr. Whelan said. In other countries, particularly European nations, such a procedure for testing is standard. The Medical Council of Canada requires students to take an exam very similar to the one being implemented by the NBME, Dr. Whelan pointed out.
You could argue, Dr. Whelan conceded, that “if I come in with a gunshot wound, I don't need a touchy, feely surgeon.” On the other hand, the bulk of medicine does, in fact, involve dialogue. And it isn't just between patient and doctor either. In this era of health care delivery, it's important to be able to interact with a variety of people, and do so successfully. “The days of the ‘cowboy surgeon’ are over,” Dr. Whelan said.
“Physicians have to know things, but they have to be able to use them in the context of patient care.”
Dr. Peter Scoles
The Federation of State Medical Boards and the NBME have begun final assessment of this new component, he added. The first phase involved medical students from three Philadelphia schools — the University of Pennsylvania School of Medicine, Jefferson Medical College of Thomas Jefferson University, and Temple University School of Medicine — and the second phase involved medical students from Georgia.
International candidates are already required to pass a test of clinical skills for certification, a prerequisite for residency training and licensing. More information on the licensing exam can be obtained by visiting the web site of the National Board of Medical Examiners, www.nbme.org, and specific information on the use of standardized patients can be found at www.fsmb.org/Policy%20Documents%20and%20White%20Papers/standardized_patient_support_white_paper.htm.