Its the NY Times, how are we to be sure that anything they write about is true anyway?
This was in the Bergen Record, North Jersey's newspaper the other day about UMDNJ-NJMS
Actors test doctors-in-waiting on real-world skills
Tuesday, June 29, 2004
By LINDY WASHBURN
STAFF WRITER
The man waiting for the doctor was weary.
The time had come. He wanted his wife to be allowed to die.
She was only 25 when their world ended in a car wreck. Now she was 31, unconscious, curled on her bed. Her limbs were red and swollen. She was missing several teeth. She drooled. Her hands were so contorted, her fingernails dug into her wrists. This wasn't the woman he married.
Steven Hewitt had prayed for a miracle. But he knew no miracle was coming.
He'd talked with her family.
Now it was time to talk with the doctor.
One by one, the doctors walked into the exam room and heard Hewitt's story. One young physician asked if he understood that the decision meant starving her to death - did he know what that looked like? Another suggested that Hewitt should get psychological counseling. A third agreed with his decision and said he'd do the same thing. A fourth said he wasn't sure how such requests were handled, but that he'd refer it to the hospital ethics committee.
Welcome to exam day at the New Jersey Medical School, where doctors in training in the physical medicine and rehabilitation department are tested on real-world skills. The OSCEs (pronounced os-keys) - for Objective Structured Clinical Examination - are not your typical, paper-and-pencil exams.
Steven Hewitt was played by an actor - a professional who's had roles on "Law & Order" and Broadway. The students each spent 15 minutes with him before moving on to five other examination rooms where similarly trained "standardized patients'' portrayed everything from multiple sclerosis to carpal-tunnel syndrome.
This exam's goal is to find out how well the students have mastered the art, as well as the science, of medicine. Call it a test of bedside manner - and more.
"You can't teach humanity,'' says Joel A. DeLisa, professor and chairman of the department of physical medicine and rehabilitation at the University of Medicine and Dentistry of New Jersey. "But you can change the things they do, their ways of saying things, how they act, how they move."
Can they listen without interrupting and ask the right questions? Do they know how to manipulate the limbs and joints to isolate and identify a problem? Can they take a good patient history and come up with an appropriate diagnosis?
The answers matter. Good communication can lead to a more accurate diagnosis, better patient compliance with treatment, and fewer malpractice suits, experts say.
Howard Pinhasik, the actor playing Hewitt, didn't hold back as he reacted to the doctors in ways most patients wouldn't dare.
"There was a certain lack of empathy,'' he told the young man who'd asked if he was ready to see his wife starve. "You made me feel like a horrible person for bringing it up. It made me feel uncomfortable and really sort of upset.''
During a break he reflected, "Doctors need to learn this stuff. It's incredibly good for them.''
The work is challenging but deeply satisfying, says Pinhasik, who, like the other actors, is paid $20 an hour for his work here. In five years as a "standardized patient,'' he's mastered 15 scenarios.
His favorite is the role of a father who learns that his daughter has been paralyzed from the neck down in a car accident. Pain, shock, self-pity, anger - he dramatizes the whole range of emotions. It's cathartic to do that 12 times in one day, he says, and good training for the theater. The young doctors sometimes are overwhelmed.
At a time when more and more Americans complain that physicians don't have time to listen, this test is a powerful statement to just-minted professionals about the importance this university places on the doctor-patient relationship.
These residents, specializing in physical and rehabilitation medicine, take this exam three times during their four-year residency. The Newark medical school also requires residents in pediatrics and internal medicine to take a similar test. Requirements at residency programs elsewhere and in other specialties vary.
Just this June, however, the national physician licensing board imposed a requirement on all students graduating from American medical schools. They must pass a 10-station clinical exam like this one before being licensed as a physician and moving on to their specialty residencies. The first tests are being offered in Philadelphia, at a cost to the residents of $975.
A similar requirement has been in place since 1998 for all graduates of foreign medical schools entering American residency programs.
This is "tremendous feedback to give a young trainee," says DeLisa, who developed the physical-medicine exam at the New Jersey Medical School in Newark. "Sometimes, the individual doesn't realize they come across as gruff, or that their physical exam is too abrupt.''
After each of these encounters, however, the patients evaluate the doctor - unlike in real life. They tell the resident whether he or she did enough to respect patient modesty, develop rapport, and prepare them for the hands-on manipulations of the physical exam.
The key question each patient answers? "Would you return to this physician for your care?''
Pinhasik had his doubts about a couple of the residents. No student has ever "failed" the exam, DeLisa said, but the feedback has been used to tell them where they need to improve. More important, it has led to changes in the curriculum so that weak skills are improved.
Faculty members also grade the students on whether they've covered all the necessary questions, performed the physical assessments correctly, and come to the right conclusions.
In Room 1, for example, a "standardized patient'' portrayed a 42-year-old woman with weakness in her right side. As the resident went through a predictable checklist of questions, the faculty evaluator watching on the computer monitor grew more and more frustrated.
"Have you fallen?'' the young doctor asked.
"Not lately,'' said the patient.
The next question should have been, "when did you fall?" Then the doctor might have heard about her fall two years ago. But the doctor didn't follow up.
Later, he asked if the patient had any problems with incontinence.
"Not now,'' she said. Again, he missed an opportunity to home in on a classic symptom of multiple sclerosis.
When the proctor, Dr. Denise Campagnolo, rushed in at the end of the session, she praised the resident for coming to the correct conclusion: The next step would be tests to confirm or rule out multiple sclerosis. But she chided him for not asking the right follow-up questions. "You're not picking up on critical pieces of information,'' she told him.
The patient, who in real life is Mary Cooney, a real estate agent, applauded the warmth and kindness of his demeanor, however. Other residents had been more coldly clinical, she said.
Cooney is a beloved member of the "standardized patient'' cast, able to master complicated descriptive scenarios where the clues are buried in the patient's history. She finds the work so rewarding, she is considering becoming a patient instructor in gynecology, for medical students learning to do pelvic and breast exams. "I feel like I'm directly affecting them as doctors,'' she says.
The $2 million, state-of-the-art center on the Newark campus of UMDNJ opened in October 2001. Each room replicates a doctor's examination room, except for the one-way window through which observers can watch, hidden microphones, and the hidden camera. Most of the encounters are videotaped so the doctors can watch themselves.
The residents are nervous before the exam, as they gather around a table in white lab coats. DeLisa explains that they will not draw any blood during their physical exams, and if they feel they need to check nerve responses with a pin-prick, they should use the Q-tips provided, instead.
"If you decide you need to do a breast, pelvic, or rectal exam - tell them, and they will tell you the findings,'' he explained. The standard patients, ranging in age from 18 to mid-70s, are physically fit enough to withstand hours of poking and prodding, but they're not required to submit to invasive tests.
Then he sends them out to their stations.
"You may begin,'' the voice on the loudspeaker intones, starting the 15-minute allotment.
"At the beginning, you're definitely a wreck,'' said Dr. Rae Davis, a second-year resident from Lyndhurst. "You know the cameras are on, that people are watching you.''
When you enter each room, he says, "You have to command the whole situation.'' The evaluators notice whether the residents wash their hands and address the patient by name.
When it's over, though, said Davis, "the feedback is great."
"You actually see yourself getting better at dealing with patients,'' said Elaine Aufiero, taking the test for her third and final time. "I feel much more confident,'' compared with previous years, she said. "It's nice to realize that you make progress."
