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http://www.nytimes.com/2002/08/27/health/27EXAM.html

Patient Gets Role in Test for Doctors

By ANAHAD O'CONNOR

ince 1998, all graduates of foreign medical schools seeking licenses in the United States have been required to pass a clinical skills test to determine whether they can effectively deal with patients.

The test, involving actors pretending to be ill, is given to foreign students who have passed the first two steps of the three-part national medical licensing examination, which American medical school graduates are required to take, and an English proficiency test.

Now, the National Board of Medical Examiners wants to ensure that all doctors have good "bedside manners," including graduates of American medical schools, by making the clinical skills assessment test a part of the national medical licensing exam. A trial program is now in place.

The clinical skills test takes place in a single day and consists of 10 to 12 personal meetings with actors carefully trained to feign illnesses and explain the symptoms. Each student has 15 minutes to gather a medical history, conduct a physical examination and provide feedback or counseling.

The students have 10 minutes to record their findings, which are later graded by a senior physician, before they move on to the next patient. When the student finishes an examination, the fake patient also grades his performance using checklists and rating scales.

"I look for certain behaviors but try to be as objective as possible," said Matt Saunders, 25, who plays one of the patients. "I look at eye contact and body language — is he standing too close or is he too far away? If I'm on the table in excruciating pain, is he sitting in a chair across the room or by my side helping me out? Is he using a lot of medical jargon that I don't understand?"

The test is being tried out at three Philadelphia medical schools: the University of Pennsylvania, Thomas Jefferson University and Temple University. In September, a second phase of testing will take place with students in Atlanta. If the pilot program is successful, the test, which students are required to pay for themselves, could become a requirement for all medical students as early as 2004.

"Most people assume that this bedside manner comes automatically to doctors in training. But we know now that's not true," said Dr. Peter V. Scoles, senior vice president of the medical examiners board. "The clinical skills component of the licensing exam will provide the public with the assurance that doctors have at least basic competency in this critical area."

Most medical schools already use actors, often called standardized patients, to test their students' clinical skills, but the new test, if adopted, will create a national standard. The test will also have a price of about $950, plus travel expenses to one of the five to seven sites nationwide that will administer it.

Dr. Jordan Cohen, president of the Association of American Medical Colleges, said he had called for the medical examiners board and the Federation of State Medical Boards to find a less expensive alternative to the test.

"The intent of the exam is one that we endorse," Dr. Cohen said. "But over 80 percent of medical students are already heavily in debt. Students have been understandably concerned about the added expense of the exam. There should be an alternative that accomplishes the same goal without such heavy costs."

Some medical students think the exam will help reduce the number of medical malpractice suits, which, some studies indicate, can result from poor communication. But almost all the students share Dr. Cohen's concerns about the exam's cost.

"I think it's a really good idea to have a clinical skills test," said Steven Crooks, a first-year student at the University of Pennsylvania medical school. "It will likely improve the average quality of patient care skills learned in medical schools, but I don't know how they will expect a lot of us to pay it."

Similar tests being used at medical schools throughout the country and in Canada, which has a national examination in place, cost several hundred dollars more, Dr. Scoles said.

"The purpose of the test is to protect the American public by ensuring that the one in 100 medical students that doesn't have adequate interpersonal and clinical skills won't practice medicine," said Dr. William Burdick, assistant vice president for the clinical skills assessment program at the Educational Commission for Foreign Medical Graduates.

"It's an expensive test," Dr. Burdick said, "but I suspect the American public would say it's worth the effort and probably would think that this is already taking place."

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