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Just what doctor ordered: a test for bedside manner

Passing a written exam is no longer enough. Medical students must show they know how to interact with patients.

TAMPA - Wearing a white coat and an earnest air, David Winchester walked into the exam room, introduced himself to Ali Manz and shook her hand.

Just the way a doctor should.

Winchester isn't one - yet. But as a third-year medical student at the University of South Florida, Winchester is part of the first class of medical students across the country who will be tested on their bedside manners. What's now a simple handshake could make the difference in whether students like Winchester practice medicine.

For 40 years, medical students have gotten their licenses by taking written tests. Now, they will be videotaped working with pretend patients.

Rudeness, arrogance, failing to listen - all those sins that so annoy patients - now could keep a student from practicing medicine.

Such failures don't just make patients angry. They also make for bad medicine, national examiners say.

"One of the sources of medical errors is the breakdown in communication between the doctor and the patient," said Dr. James Thompson, president and CEO of the Federation of State Medical Boards, which co-sponsors the test. The federation and the National Board of Medical Examiners agreed to require the test of all prospective doctors starting with the class of 2005.

A survey last year found that one in five patients reported problems talking with doctors. Patients said they had questions they couldn't ask, that they didn't understand doctors' information, or that doctors didn't listen, according to the Commonwealth Fund, a foundation that supports research on health issues.

That disconnect has been overlooked, said Dr. Peter Scoles, senior vice president of the National Board of Medical Examiners.

"Communication skills ... have been underemphasized in the practice of medicine," Scoles said. "You can't be a walking textbook and practice medicine adequately."

He believes the new test has a symbolic importance that will resonate beyond medical school.

"This is a tremendous statement by the medical profession to the public," Scoles said. "It says to them, "You count. You're important, and what you have to say matters."'

The topic is getting more attention. A study to be published in a national journal this week will evaluate how teaching communication skills to medical students affects them.

Others are dubious. The test will hurt students more than it helps patients, said Dr. Ed Farrior, president of the Hillsborough County Medical Association.

The real reason it's hard for doctors to connect with patients is the way they're being squeezed by managed care, Farrior said.

"Doctors have got to see so many patients to make a living these days, they don't have time to sit in a room and communicate with them," Farrior said.

An earlier Commonwealth Fund survey backs Farrior's point. In the 1997 survey, 41 percent of doctors said they had less time to spend with patients than they did three years earlier. And doctors with more managed care patients were twice as likely to say they were rushed.

But at the USF medical clinic the day Manz and her mother are there, time is not a problem.

Ali Manz, 20, is a USF junior. With spiky blond hair and a faded T-shirt, she still looks like the soccer jock she was in high school. But her voice was hoarse with congestion. Her mother wanted to know why she keeps getting sick.

For a while, Winchester just listened, trying to make sure he didn't miss anything. Then he asked about Ali's symptoms and history. He even joked with her when her mother misstated her age.

Mother and daughter liked him. He was thorough, they said. He listened. He explained.

Even so, Maria Manz likes the idea of a test. During her father's final illness last year, she dealt with too many doctors who didn't seem to care.

"We've seen some bummers," she said.

Some spoke so fast, all in medical jargon. Some vanished before she could ask a question. One seemed to confuse her father with another patient.

Until 1964, medical students were tested on their skills in dealing with patients. Then the test was dropped because it wasn't reliable, Thompson said.

But the debate simmered, and in the early 1990s, work began on a more objective test.

The final result is elaborate. In their fourth year of medical school, students must pay a $975 fee and travel to a national testing center. Florida students will go to Atlanta. There, each student faces a clinic of 10 patients, one after another.

Only the patients aren't really sick. They're actors with imaginary symptoms: a cough, chest pains, headaches.

Students will ask questions, listen, examine patients. They'll tell the patient what treatment or tests may be needed and write a quick report on each patient's condition.

Each exchange will be videotaped and studied. The actor-patients will give opinions. And the students' written charts will be reviewed.

Examiners will see whether students picked up the right medical clues. They will also look at interaction. Did the student establish a rapport? Listen?

"You can actually fail the exam for not listening to the patient," Scoles said.

Just as in real life, there can be more than one right answer, said Dr. Paul Wallach, associate dean for curriculum and medical education at USF's School of Medicine. If a patient complains he can't afford a new medicine, a student could review all the patient's medicines to reduce costs or send the patient to a social worker to find services to help.

"A wrong answer would be, "Well that's your problem,' and move on," Wallach said.

Still, even the way students ask questions matters. Scoles likes broad questions and a manner that invites patients to raise concerns. "If I were to ask you a series of very rapid, closed-end questions and didn't give you a chance to respond," it would be points off, he said.

Examiners also want students to be sensitive and nonjudgmental. The student who asks, "Are you sexually active?" is more likely to learn a patient's real health risks than the one who says, "You're not married, so you're not having sex, are you?"

Many students have mixed feelings about the test. Winchester and Karl Waite, another USF medical student, said clinical skills are vital. But USF already stresses those skills, they said, and they would prefer to be tested there.

"We've been prepared for this all along," Waite said. "The bad thing is it costs a lot of money."

But Scoles said an objective test is needed. And it's past time, he said, to test how students doctor.

"In all my years of practice," he said, "I never had a patient come into my office as a five-part multiple choice."

Part of the communication gap is a natural imbalance. Patients confront their deepest fears in an examining room, while doctors pace through another day at the office.

So maybe it's not surprising that asking patients about doctors' listening skills is like scratching a scab. Irritation flows.

"You wait to get your 15 minutes, and they don't seem to be listening," said Seminole resident Lesley Reynolds, 34. "It's hard to help people when you don't know what's going on."

Madeira Beach resident Cindy Fearon, 57, has finally found a doctor she likes - a woman who cares about Fearon's health almost more than she does.

"I had breast cancer in 1981, and she acts like it was last month," Fearon said.

Before that, she had too many doctors who didn't want to ask questions or hear her answers. Fearon is sure many people share her fears and won't talk to uncaring doctors.

"I'm afraid of doctors," she said. "So I only tell them what I'm prepared to deal with."

At a patio table at St. Petersburg's BayWalk one recent evening, Kim Saunders hiked up her jeans to show off a scar. The first doctor got X-rays of her ankle, found nothing and told her the pain was all in her head.

The second told her: "If you're having pain, it's a problem," and ordered the MRI that found the cyst behind her Achilles tendon.

She thinks the new exam is a great idea.

"Unless you're in the lab, it's a people business," she said.

Saunders, 34, a Peace Corps veteran who was visiting St. Petersburg from her home in Virginia, has another reason for her interest in the test.

She and a friend were sitting at BayWalk that evening discussing her future.

Saunders' next stop: medical school.

Dr. Paul Wallach teaches doctors how to talk to patients. Wallach, associate dean for curriculum and medical education at the University of South Florida College of Medicine, also has some tips to help patients talk to doctors:

- Write down your questions before you come to the office. If possible, bring two copies: one for you, one for your doctor.

- Keep a list of the medications you're taking and bring it to every visit. That way you don't spend the time with your doctors trying to guess the name of each medicine instead of talking about issues.

- Keep a similar list on preventive care, giving dates of your last mammogram, pap smear, colonoscopy or other procedures.

- One of doctors' biggest concerns, Wallach said, is the legions of patients who reveal their biggest fear as the doctor is walking out, as in, "Oh, by the way, I'm having chest pains."

"Make the "Oh, by the way,' comment first," Wallach advises.

- If you feel your doctor isn't addressing your questions, Wallach suggested bringing that up in a nonconfrontational way. His approach: "I didn't really feel today I had time to have all my questions answered. I wonder if we can make another visit, where we can address those."

Here are a few jokes about doctors collected from various Internet sites.

- A man goes to his doctor for a complete checkup. He hasn't been feeling well and wants to find out if he's ill. After the checkup the doctor comes out with the results of the examination.

"I'm afraid I have some bad news. You're dying and you don't have much time," the doctor says.

"Oh no, that's terrible. How long have I got?" the man asks.

"10 . . ." says the doctor.

"10? 10 what? Months? Weeks? What?!" he asks desperately.

"9 . . . 8 . . . 7"

- A woman goes to her doctors' office and is seen by one of the new doctors. After about 4 minutes in the exam room, she bursts out, screaming as she runs down the hall. An older doctor stops and asks her what the problem is, and she explains.

The older doctor marches back to the first and yells, "What's the matter with you? Mrs. Terry is 63 years old, she has four grown children and seven grandchildren, and you told her she was pregnant?"

The new doctor smiles smugly as he continues to write on his clipboard. "Cured her hiccups though, didn't I?"

- A man asks his doctor if he thinks he'll live to be 100. The doctor asks the man, "Do you smoke or drink?"

"No," he replies, "I've never done either."

"Do you gamble, drive fast cars, and fool around with women?" inquires the doctor.

"No, I've never done any of those things either."

"Well then," says the doctor, "What do you want to live to be a hundred for?"