Ounce of Prevention

Medical students must pass a new and costly "bedside manner" test.



Shane Asbury lightly knocks at the door before entering the room. His next patient waits inside on an examination table. "Hello, ma'am. I'll be doing your exam today. It says here that you have a cough," says Asbury, consulting the patient's chart. "Tell me about it."

For the next 15 minutes, Asbury's every move and every word are observed and graded. If he passes, he takes one step closer to becoming a doctor.

No pressure. At least, not yet.

Asbury is one of six University of Tennessee Health Science Center students participating in a simulated examination in preparation for a national standardized test. The test, called the Step 2 Clinical Skills exam, is aimed at measuring a medical student's bedside manner. The test, instituted in June, is a new component of the three-step United States Medical Licensing Examination.

The Step 2 CS is a one-day exam in which students are graded on their interactions with 11 or 12 people trained to act like real patients. Students read a patient's vital statistics before entering the examination room, then they encounter one of about 25 common ailments seen in doctor's offices from abdominal pain to migraine headaches. Students use the information they gather to write an assessment of the patient's condition.

The test sounds good in theory, but some UT students say the Step 2 CS is unnecessary.

Students participating in UT's simulation are fourth-year medical students who must successfully complete the test before beginning their residency programs. They contend that by the time they reach their fourth year, they've already had similar training and tests. "We have been doing this type of program here at UT for about four years," says assistant dean of academic affairs Robert Shreve.

Students taking the national test must do so at one of five testing sites around the country: Chicago, Los Angeles, Philadelphia, Houston and the UT students' closest option Atlanta. Test registration is $975. Students are also responsible for transportation, lodging, and other expenses.

For Asbury's classmate and future pediatrician Laura Goss, the price is too high. "Some of [my classmates] are taking the test before the end of the year, but I'm not taking it until I can come up with another $1,000 and that probably won't be until February," she says. "Don't get me wrong. It's a good test, and I could see the need for it at some schools, but here, where we are involved with patients throughout our curriculum, we don't need another test."

Future pathologist Doug Hof is more adamant in his dislike of the Step 2 CS. "There is a similar component in Step 3 [of the USMLE] already. I think the National Board of Medical Examiners spent so much on these test sites and on the early trials that they had to go through with it. Just being in a room with someone for 15 minutes in front of an observer does not show whether or not I can interact with my patients. Of course, I'm going to be on my best behavior during that time."

Jennifer Ware is the training manager for the "patients" used in UT's simulations. "Sure [the students] would rather not take the test," she says. "Even the American Medical Association has been critical of the test because of additional costs."

But Gail Beeman, director of UT's CS program, says the new test has merit. "When it's administered in the first two years of study, we've found that those students have a problem sometimes with closing or ending patient encounters," she says. "Older students are more aware of those things, but they sometimes still get nervous and forget to call patients by name, which is what patients like."

The Step 2 CS test began almost a decade ago as an assessment for foreign medical students. In its current form, all students are given a one-year window of eligibility, based on their registration date, to take the exam. Passing this portion of the exam is a prerequisite to the Step 3 test.

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