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Better Bedside Manners

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Every patient wants to find a doctor who listens. But wouldn't it be easier if all doctors were just better listeners? A new paper in the Sept. 5 issue of the Journal of the American Medical Association suggests that it might not be so hard to make it happen: in the first comprehensive study of clinical-skills exams given to doctors, researchers from McGill University in Montreal show that poor scores in the communication portion of the test are highly predictive of which new doctors are likely to clash with patients in the future. By evaluating communication skills early on, say the study's authors, physicians and academics can better train and select the next generation of medical professionals.

For their study, the McGill researchers tracked all 3,424 physicians who took the Medical Council of Canada clinical-skills examination between 1993 and 1996, and who were then licensed to practice in Ontario or Quebec. The exam, which was rolled out between 1992 and 1993, requires doctors to interact with actors posing as patients in a series of standardized scenarios; trained physician evaluators then judge how well the doctor takes patient histories, makes diagnoses, manages treatment and communicates with the patients.

When researchers followed up with the doctors in 2005, they found that the docs' scores in communication were strongly correlated to the number of patient complaints they had racked up in their first years of practice. Overall, the 3,424, physicians had 1,116 complaints among them, of which 696 were deemed valid after medical-authority investigation. The physicians who scored low on the test — the poor communicators, who were, say, condescending, judgmental or flippant in their behavior — had generated a disproportionate number of those complaints. Doctors with scores in the bottom quartile on the test's communication-related portion had 70% more legitimate complaints per year of practice than the top-quartile performers; the poor communicators had 4.3 complaints per 100 doctors per year while their higher-scoring peers had 2.5 complaints per 100 doctors per year. No surprise: the link between poor test scores and patient complaints was strongest when it came to doctors' style of communication and attitude — the way a doctor tells a patient he has cancer, for example, or whether a doctor ignores a mother's description of what ails her child.

The current JAMApaper is the first to measure how accurately a standardized test can evaluate doctors' skills and how effectively those grades can predict future patient-complaint rates. According to the study's authors, when patients complain in the U.S. and Canada, it's most often about doctorsĺ communication or attitude problems, rather than, say, quality-of-care issues or office screw-ups. And plenty of past studies have shown a link between lousy doctor communication and poor medical outcomes, such as inadequate care and malpractice suits.

Now that doctors know the exam works pretty well, maybe more countries will put it to use. When Canada first mandated that doctors pass the communication test for licensure, it was the only country in the world to do so — and the move was seen as controversial. Since then, the U.S. licensing system has also introduced a clinical skills exam, which every domestic and foreign medical school graduate must pass. Robyn Tamblyn, the lead author of the JAMA paper and a professor of medicine at McGill, thinks the test ought to be given even earlier than that. Why have doctors slog through med school only to be pushed out of the profession afterward because their bad bedside manner? Tamblyn recommends testing students' aptitude for communication as part of the med-school admissions process, or at least testing students early enough in medical school that they can get remedial help if they need it."I think that's the most efficient thing to do. I think that way, essentially, you raise the bar," says Tamblyn.

While few physicians or educators doubt that communication matters, many people question how well you can test something as subjective as communication — especially when every new doctor must complete the exam on a single given day, no matter how grouchy he or she feels. But both the Canadians and the Americans have gone to great lengths to ensure their tests are fair, says Tamblyn. Her study shows that the predictive power of such exams holds irrespective of the doctors' gender or whether they went to med school in another country. "It's a good-news story," says Tamblyn of her study. If we know how to evaluate what makes a good doctor, after all, maybe we can produce better ones. "This could diminish quite substantially the number of complaints," says Tamblyn.