New licensing requirement puts pressure on other med schools

Beginning next fall, a new portion of the exam used to certify doctors will test candidates' ability to communicate with patients.

The United States Medical Licensing Exam (USMLE) will test doctors through an assessment of interactions between the student and a standardized patient during an interview. In response, many medical schools are introducing courses to teach students these skills.

The Tufts School of Medicine is one of the few schools that already offer such a course that teaches these skills. Dr. Jonathan Schindelheim is the course director of Interviewing and the Doctor-Patient Relationship, a required class for first years that he has taught for over 20 years.

"Tufts has always been focused on building good clinicians, and doctor-patient relations skills are essential to this," said Schindelheim.

The mass movement towards better communication began in 1995, when two organizations that accredit medical schools started requiring instruction in this area. Since then, approximately 12 schools, including Tufts, Harvard, Brown, and Northwestern have pushed clinical skills with students.

Good communications skills among doctors "change a culture of blame to a culture of safety," explained John Fromson of the Massachusetts Compassionate Care Coalition. He said that most errors leading to malpractice suits are due to poor communication.

However, according to Schindelheim, the class cannot be the sole component of a student's education in clinical skills.

"The skills must be developed, and then they must be practiced," he said.

Research seems to support the idea that these classes are effective. A recent study published in the Journal of the American Medical Association (JAMA) indicated a five-percent increase in performance on a standardized test on communication skills after taking a class on doctor-patient relations.

Although the change is relatively small, Madge Kaplan, a journalist for National Public Radio who recently hosted a program addressing the topic of doctor-patient relations, believes it is still worthwhile to teach communication skills. "I think the evidence is clear that patients really want better interactions," she said.

But a recent opposing article in JAMA questioned the development of doctor-patient relations classes. The article claimed that there is no standardization of the curriculum or of the amount of time spent teaching the skills.

Kaplan disagrees. "I really think from my research that the whole effort seems to have been very carefully conceived," she said. Kaplan has noticed that some institutions, like Tufts, have "really gone the extra distance, wanting to put more resources into this sort of education."

There is, however, concern that students might abandon the skills learned once they become practitioners. Jim Hayes is a member of Match-Up Interfaith Volunteers, a program that helps the elderly lead active lives who has often accompanied patients on their appointments with doctors. He wonders whether even the new portion of USLME, given during the fourth year of medical school, will be an accurate indicator of how doctors will behave in practice.

"If the student knows they are being evaluated on a certain day, naturally they will be polite," Hayes said. "But what happens when they're actually in practice and the pressures of the hospital set in?"

Other critics take issue with the clinical skills examination itself. Dr. Stephen Lurie, who wrote an editorial in JAMA on the topic, believes that the skills can be taught. He does not, however, agree with the idea that they can be measured.

"The idea that communication is a single thing, that you have it or you don't, is simplistic," he said. "There is no widespread agreement about what communication is and hence how it can be tested."

But according to Hayes, who runs a workshop to help the elderly communicate more effectively with their doctors, the responsibility for better relationships does not fall solely on the doctors. "It's the patient's responsibility to check the doctor sometimes," he said. "The relationship should be an equal partnership between two intelligent adults. There is 100 percent responsibility on both sides."

Fromson blames some of the lack of communication on the fact that doctors now are required to see more patients in less time. "Doctors don't purposely cut out simple considerations," he said, "but it just happens in a stressful situation. We have to work really hard to reestablish that deeper connection doctors should have with patients."