Which of the following would you as the patient prefer to find in your physician? (A) Encyclopedic knowledge of the human body in health and disease. (B) Practical wisdom of how to treat and prevent illness. (C) Skill in safely performing surgery and other medical procedures. (D) Compassionate bedside manner including the ability to listen and to communicate effectively. (E) All of the above.
Multiple-choice tests have long been the standard means of assessing competence in medical students about to become physicians. Yet, as the preceding multiple-choice question suggests, there is more to the art of medicine than can be measured by a written test.
Beginning in June 2004, medical students must now pass a national skills test on personal interaction and communication to be eligible for licensure. This clinical skills component of the U.S. Medical Licensing Examination (USMLE) consists of a one-day structured examination in which students will be observed interacting with 12 simulated patients. Simulated patients are laypersons trained to mimic common ailments. Students will be graded on their skills in taking a medical history, examining the patient, writing a chart note, and communicating clearly with the patient.
Just as pilots and astronauts in training must pass tests in flight simulators, medical students must now demonstrate proficiency in the practical skills of encountering patients. Those who pass will advance to residency training as the rough equivalent of copilots in the hierarchy of medical training, still years away from independent flight.
Critics have objected to the cost of the test, which at $975 plus travel expenses to one of the five hosting sites across the country is no small burden to medical students who already face debts at graduation averaging in excess of $100,000. This cost is comparable, however, to that of other standardized exams physicians in training must take, and is necessary for the test to be organized in a way that ensures a consistent standard of validity and fairness.
The regard for cost is incomplete unless one also considers value. The test is an investment in curtailing the much higher cost to society—to patients, their families, and to physicians—from errors due to miscommunication in medical practice. Imagine the havoc that could disable a major airport if not for precise and effective communication systems. Communication is even more critical in medicine.
Solutions to the problem of how to prevent medical error have been sought primarily through technology. In this age of computers, automated methods of improving the accuracy and efficiency of the flow of information are available and should be utilized as long as they do not jeopardize the confidentiality of the medical record. Technology alone, however, will not suffice. When it comes to the delicate task of gathering health information from the patient, and to the sensitive mission of imparting knowledge and wisdom to the patient, there can be no substitute for the human voice and touch. Anyone who has received from the pharmacy a multiple-page printout listing all the side effects known ever to have occurred in the history of a dispensed drug knows that raw information can be unsettling, and uninterpreted knowledge of risks can be burdensome.
Introducing a national bedside exam also addresses needs beyond safety. As important as safety is, if medicine could only guarantee safety for patients without sustaining compassionate care, something precious would be lost. With advancing technical power comes an increasing need to preserve the physician’s human face. If patients are to be heard and understood, physicians must be well trained to listen and to speak with clarity and concern. While no test or clinical guideline can compel compassion, the expectation that students should pass exams that assess not only book knowledge but also people skills demonstrates how seriously the medical profession takes its responsibility to engender in its students the kind of relationship physicians ought to have with their patients.
The clinical skills examination reaffirms the importance of medical education’s traditional commitment to teaching students how to enter into the distinctly human exchange that transpires at the bedside. Here, where the patient is most vulnerable, the physician’s conduct in mediating technology makes the difference between a procedural task and a healing encounter. Although most medical schools already emphasize this and test for it, the public has been telling us for years that not all licensed physicians demonstrate, or at least retain, sufficient skills in bedside manner. The new exam is a decisive response to that need.
The multiple choice examination with its emphasis on recalling facts, recognizing patterns, and engaging in abstract reasoning, models imperfectly the medical consultation with a real patient. Adding a bedside examination comes closer. The medical consultation is a special occasion in which the patient is able to sit down face-to-face with a doctor whose sole purpose at that moment is to bring the benefits of 24 or more years of education to bear on that person’s immediate need. The physician at his or her best does not consider medical knowledge something to be grasped for the sake of intellectual enhancement, but rather, taking on the role of a servant, obediently applies knowledge and skill to the benefit of the patient. In humility, the physician considers the interest of the patient to be more important than his or her own.
As with any test, there are limitations. Left unmeasured is the willingness to sit down with a patient and explain the meaning of a disease. Untouched is the physician’s skill in breaking the news of a life-threatening diagnosis or guiding the patient through an ethical dilemma. Absent from the analysis is the physician’s skill in responding to the patient overwhelmed by disease, or to the dying child. These are just a few examples of how much more is involved in medical training. Examinations are but steps along the way.
Realistically, this is not a test to end all testy doctors. The most caring physicians are imperfect human beings. Despite good intentions, physicians do not always succeed in maintaining unblemished composure under the fatigue, frustrations, and frequent interruptions that characterize the reality of medical practice. Such pressures can be more successfully navigated, however, by habitually practicing the communication skills learned in training. Examinations complement the example of mentors in upholding an ideal standard of professional conduct.
The clinical skills examination is a welcome development in medical education. This bedside test will help preserve the high standard of communication that ought always to characterize the medical profession, even when external forces jeopardize time meant for the bedside. In the interest of preparing their students to pass the test, medical schools will unite in renewing their emphasis on teaching students how to listen, to speak with sensitivity, to create rapport, and to become doctors who are not only technically skilled but also who have a bedside manner that fosters trust and promotes healing.
Papadakis MA. The step 2 clinical-skills examination. New England Journal of Medicine 2004; 350:1703-1705.
Fromm M. Medical students tested for people skills. The Washington Times, June 28, 2004.
William P. Cheshire, Jr., “Benchmarking Bedside Manner in Medical Education,” Dignity 10, no. 3 (2004): 2–3.