Starting with the Class of 2005, medical students across the country will have to pass a new Clinical Skills Examination -- testing observation, diagnosis and bedside manner -- if they wish to continue their careers as licensed interns.
Administered by the National Board of Medical Examiners, the exam-- which features "standardized patients," trained to exhibit consistent symptoms and attitudes --forces students to deal with a variety of situations, including angry patients and the bearing of bad news.
Foreign medical school graduates wishing to work in the U.S. have been required to take a similar test since 1998. A similar national test was in place before 1964, when it was dropped due to concerns of objectivity.
"Conceptually there's almost unanimous agreement" that such a test is needed, NBME Senior Vice President of Assessment Programs Peter Scoles said. "Having a lot of knowledge doesn't guarantee that you have this set of skills."
Scoles estimated that the CSE "will remove from practice 75 to 125 people per U.S. graduation year who lack even the basic abilities to speak with patients and gather information," noting that the public benefits by being insulated from potential doctors who could not "gather information and give information back in a manner that can be understood."
The logistics of the $975 exam, however, have invited criticism from the American Medical Association -- and groans from traditionally debt-burdened medical students who must foot the bill for test fees and travel to a testing site. The test will only be administered in Philadelphia, Atlanta, Chicago, Houston and Los Angeles.
Speaker of the AMA House of Delegates Nancy Nielsen explained the organization's reservations about the exam.
"I agree with the people at the NBME [that]... an exam that measures a medical student's clinical skills is a good thing," Nielsen said. "We like the exam -- we don't think it belongs as part of licensure."
Nielsen said that having medical schools administer the test would make more logistical sense.
Nielsen, an associate dean at the University of Buffalo School of Medicine, empathized with students stuck traveling long distances even to the closest testing center.
"It's not so easy to get from Buffalo to Philly," she said. "And that's where they're going to go."
Scoles countered that medical students typically take "12 to 20 trips" in their senior year to investigate post-graduate opportunities around the country, making the extra travel just a drop in the bucket.
"This fits into what they normally do," he said.
Scoles added that, while "the AMA opposes the price, the cost of the examination is less than two years AMA dues."
"I would think that the public gets more benefit out of this," Scoles said.
However, Nielsen maintained that "these skills are taught in the majority of medical schools right now."
Offering CPR training as an example, Nielsen said that, while "you would not want a physician who did not know how to do CPR," no one has suggested taking "Every one of the 16,000 medical students in the country to Philadelphia and laying out those mannequins."
"It's delegated to others -- that's the same thing that we're recommending be done here."
Suggesting that the Liaison Committee on Medical Education, which accredits medical schools, would only have to "strongly recommend" that programs adopt a clinical skills exam to ensure that all accredited medical programs were on board, Nielsen noted that her own university requires students to demonstrate clinical competence for promotion to their fourth year.
She added that testing within the schools made educational sense as well, noting that "not only are clinical skills taught in the medical school, but that's where they ought to be tested, and... remediated."
Penn Medical School's Vice Dean for Education Gail Morrison said she doesn't anticipate any problems preparing her students for the exam.
"They always say, you never teach to the test," she said. "Let's face it. SAT's are there, people certainly prepare for them.... This forces medical schools to be sure that [clinical training is] within their curriculum -- if not, those students aren't going to pass."
Having had a standardized patient program in place since 1997, Penn is ready to "find those students first... even before they take that test" to ensure that those taking the clinical skills exam are prepared. Fees for the exam will likely be absorbed into the school's four year tuition plan.
A test site for the exam, Penn performed perfectly.
"We didn't have anybody that failed when we did the pilot," Morrison said.
The NBME test center in Philadelphia will be located near 40th and Market Streets according to Morrison, and will administer the first round of exams next spring.
