Medical Students Prepare to Examine Patients in New National Exam

BY ERIC LEVY
MEDICAL SCHOOLS VARY IN THE WAYS THEY TEACH CLINICAL skills and the standards they use to evaluate skills. A new clinical skills exam has been added to the U.S. Medical Licensing Exam (USMLE) to establish a national standard that all students must meet before they practice medicine.
Medical school students scheduled to graduate in 2005 will be the first class to take the exam. More than 15 years of pilot testing have gone into making sure the exam will be a reliable and objective way to test clinical skills.
The exam, which will start in June 2004, is being incorporated into Step 2 of the USMLE. Since 1992, Step 2 has consisted of a multiple-choice clinical knowledge test that focuses on principles of clinical science that are deemed important for the practice of medicine under supervision in postgraduate training. The decision to make a clinical skills test a requirement for medical licensure resulted from research showing that such exams can measure what traditional, multiple-choice exams cannot — the ability to communicate effectively with patients and colleagues, take patient histories, and perform physical exams.
The one-day exam for students at the end of their third year mirrors a physician's typical workday in a clinic. Students will examine at least 10 standardized patients — actors coached to portray patients with specified clinical histories — who go through extensive training to minimize any bias that could interfere with the exam. They are selected to represent a broad range of age, racial, and ethnic backgrounds. After each encounter, the standardized patients assess student performance using checklists and rating scales. Physicians and testing professionals watch samples of videotapes of the interactions to assure objectivity and fairness in the final scoring.
After each exam, students record pertinent history and physical examination findings, list diagnostic impressions, and outline plans for any needed follow-up.

P&S Students and Standardized Patients
In a clinical practice course taught to P&S students during their first and second years, students interact with standardized patients to focus on communication with patients. In the course, taught by Dr. Ora Pearlstein, assistant clinical professor of medicine, the students receive early exposure to this method, providing an opportunity to practice specific interviewing skills such as taking a sexual history, identifying substance abuse and domestic violence, dealing with end of life issues, and giving bad news. Students experience a session doing a complete history and physical examination with standardized patients, comparable to what they will face on the USMLE exam, at Mount Sinai Medical Center's Morchand Center for one full day in their third year. Students examine standardized patients, and their sessions are videotaped.
Dr. Rita Charon, professor of clinical medicine and director of the clinical skills assessment program at P&S, says the videotaped sessions at Morchand "are a valuable teaching tool. Faculty members can show students how they've performed and as they watch some say, ‘Oh, I did that?' and change accordingly. Others see that they're capable of doing a lot better than they thought."

Actor Mark Hattan poses as a patient with a sexual dysfunction problem who requests a Viagra prescription from Gina M. Badalato'07 in a simulated patient interview during Clinical Practice I.
Concerns of the Class of 2005
Anything new naturally causes concern. One concern of P&S students about the new clinical skills exam is cost — the Step 2 clinical skills exam has a price tag of $975. Students must pay for the test plus the cost of transportation to and lodging in one of five test centers: Philadelphia, Atlanta, Los Angeles, Chicago, or Houston.
Dr. James N. Thompson, president and CEO of the Federation of State Medical Boards of the United States, which sponsors the USLME along with the National Board of Medical Examiners, says the importance of the exam justifies its cost. "One of the responsibilities of us as professionals is to put the interest of our patients above our own self interests, whether they be financial or social — it's part of the definition of being a professional. It's the right thing to do for physicians and for our patients."
P&S students say they are also concerned about the objectivity of the standardized patients, despite assurances. "What if the patient thinks I'm holding the stethoscope the wrong way? Will he take off points for that?" asks Katherine Holman'06. "It doesn't seem easy to give a numerical score on how we relate to the patient. If it turns out to be fair, however, then I believe it's beneficial." Other students, such as Christopher Kepler'05, believe the test is unnecessary. "It undermines medical education in the United States to suggest we're not competent in communicating with patients. There may be some people who are not up to par in clinical and communication skills, but it doesn't justify burdening all medical students across the country with the cost and inconvenience of taking the exam."
Most students from the P&S Class of 2005 feel prepared for the exam and anticipate a passing grade. "It's not the best feeling that we're part of the guinea pig class," says Monjri Shah'05, "but we'll have gone through the same thing at the Morchand Center and we're tested on the communication aspect in clinical practice classes with standardized patients. It's only a pass/fail exam. I think P&S students will do very well."

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