Manner matters for new doctors

Test will assess skill in interacting with patients

BY JONATHAN MAZE
Of The Post and Courier Staff
For all the advancements in medicine over the past several decades, some of the best health care still comes down to that few minutes when a doctor asks a patient what's wrong.

This means that bedside manner is just as important as the doctor's knowledge of the difference between a cluster headache and a migraine.

It's so important, in fact, that the National Board of Medical Examiners has spent 15 years figuring out how to test it properly. This week, some of the nation's soon-to-graduate medical students began taking that test. Known as the "clinical skills assessment," the test grades students' performance in examining actors posing as patients with various health problems.


YALONDA M. JAMES/STAFF
Administrative assistant Carol Woody (from left), Maura Carey, director of the Center for Clinical Evaluation and Teaching at MUSC, associate medical school dean Amy Blue monitor rising fourth year medical students as they examine actors posing as patients at the McClennan-Banks Clinic on Friday.

Becoming an M.D. now means having to show concern for patients as people.

"When doctors and patients don't communicate effectively, that's when medical mistakes happen," said Dr. Peter V. Scoles, senior vice president for the National Board of Medical Examiners in Philadelphia. "Patients very rarely come in with multiple-choice questions. They've got a problem. The doctor's got to fix it."

While patients are sure to love the idea of it, the bedside manner test has its detractors.

Both the American Medical Association and the American Medical Student Association have come out against the test, saying it puts an unnecessary burden on students when most medical schools and residency programs already teach bedside manner.

That burden, in part, stems from the test's price tag -- $975. What's more, students can be tested at only one of five sites around the country: Atlanta, Chicago, Philadelphia, Houston and Los Angeles.

"I'm not exactly opposed to the test," said Nicole Redmond, who is entering her fourth year at the Medical University of South Carolina's medical school. "I'm opposed to going that far and paying that much."

Until now, anyone wanting to become a physician in the United States needed to graduate from medical school, undergo some post-graduate training and complete a three-part licensing exam. The National Board of Medical Examiners and the Federation of State Medical Boards will administer the new exam, known as the U.S. Medical Licensing Examination.

There has not been a test that has looked at bedside manner since 1964, when such tests were abandoned because they were considered haphazard and inconsistent. The national board has spent $25 million and worked for 15 years to develop the new standardized test, Scoles said.

The new test lasts much of the day. Students will see 12 different "patients" for 15 minutes apiece and get another 10 minutes to record the patient's history and possible diagnoses.

The patients are actually hired actors who come from all walks of life, from teenagers to retirees. They're paid $18 an hour and act out a number of scenarios. They're also the ones who grade the medical student, Scoles said.

Each "patient" has had a total of 60 hours of training and has acted out his or her scenario 60 times in preparation for the evaluation. Scoles said they are continually monitored even after certification.

Those evaluating the test will be looking for three things: the would-be doctors' ability to gather information; their ability to establish a rapport with the patient; and their ability to speak clearly in English.

Students either pass or fail the test, though few will have to take the test a second time. Scoles said 95 percent of the students are expected to pass it on their first attempt, while nearly 99 percent are expected to do so on subsequent attempts.

"Those who don't pass on repeated efforts have problems and shouldn't be doctors," Scoles said.

Dr. Jerry Reves, dean of MUSC's medical school, believes his students will do well. "We are confident that 100 percent of our students will pass it," he said.

Reves said about two-thirds of the nation's 126 medical schools have programs designed to evaluate their students' skills in this realm and that MUSC is one of them.

The university has evaluated students using actors as patients in what is known as its Center for Clinical Evaluation and Teaching for nearly 10 years, said Maura Carey, the center's director.

When the National Board of Medical Examiners was testing its test in 2000 and 2001, it used MUSC as one of its pilot sites, said Amy Blue, associate medical school dean.

MUSC has had a bedside manner test similar to the new standardized version for the past five years as a requirement for graduation. This year, MUSC will begin testing fourth-year students in July, one month earlier than normal, to help them prepare for the standardized test, Blue said.

MUSC uses a variety of actors as patients, who, like those in the national exam, evaluate the students.

On Friday, for instance, a group of students finishing their third year of medical school each visited four "patients," including "Maria Cortez," a Hispanic patient complaining of chronic headaches.

One of the women playing Maria was Mary Ellen Duffy, a retired Spanish teacher. "When we were trained to be teachers, we practiced teaching before we went out in the real world," Duffy said. "I'm glad they're doing this earlier in medical school so they can fine-tune their skills before doing it with actual patients."

The students who were evaluating "Maria" will be among the first class required to take the new test. Most said their experience doing this, along with rotations they do in the hospital, prepared them well. "I'm not going to worry about it," student Colin Widener said.

Redmond, on the other hand, worries that she may have trouble with the clinical exam, in part because it's videotaped. "I don't like the Big Brother camera," she said. "It seems so judgmental."

Preston Wendell, another rising fourth-year student, said it's difficult to determine a future doctor's bedside manner in a single test. "It's just a snapshot," Wendell said. "Anyone can go and fake niceties for half a day."

Scoles said he's sympathetic to concerns about the price of the test, especially coming amid dramatic increases in medical school tuition and skyrocketing student debt loads. But the test is vital to ensuring the best patient care, he said.

"This is an expensive exam," Scoles said. "But the cost of not doing it is much, much higher. We can put a price tag on what the exam costs. It's impossible to put a price on mistakes that occur from lack of effective communication."


MIND YOUR MANNERS

For the first time this year, graduating medical students will have to take a test of their clinical skills by examining actors posing as patients with varying problems. The test will look for three things:

-- The ability to gather information from patients by taking a history and performing an exam.

-- The ability to establish a rapport with the patient, convey a sense of concern and make certain the patient understands the treatment.

-- The ability to speak English well.

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Carpe Diem
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St. Matthew's University School of Medicine
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