The Standardized Patient Exam
JUST ANOTHER (COSTLY) TEST.The New Physician
Standardization has become the norm in medicine. Physicians deliver a standard of care. Academic standards are upheld through licensing examinations. Standard billing and coding routines dominate medical offices’ daily practices. And the standardized patient exam, or SPE, has been praised as the long-sought tool for evaluating a physician’s efficacy in the clinical setting.
The effectiveness of the SPE in evaluating physicians’ clinical proficiency, however, remains to be proven. My personal experience with the SPE makes me wonder whether the National Board of Medical Examiners (NBME) has found the “magic bullet” of clinical evaluation in its proposed clinical component (to be given to the class of 2005) of the United States Medical Licensing Examination, or whether it has simply stumbled upon another “dud”—an exam tool that does little more than appraise students’ abilities to recite memorized information and perform rehearsed clinical rituals. In its essence, the SPE differs very little from traditional NBME examination tools. This time, though, the stage is the exam room, the patients are actors, and the high price of admission lands firmly on the student’s pocketbook.
But back to my experience. As part of my medical school’s clinical medicine rotation, course directors evaluate students’ proficiency in the outpatient setting by using a form of the SPE. Before taking the exam, the other students on the clerkship and I figured the undertaking would be an enjoyable experience; time spent in the clinic is much more interesting and much less painful than hours spent on a written exam. And an exam using real people placed in plausible clinical scenarios seemed a pleasant, objective means of evaluating our ability to communicate and solve problems in a clinical setting. After all, we were in this to be good physicians, and wouldn’t an exam evaluating a physician–patient relationship be just what we had always wanted?
When the exam day arrived, we reported to the testing site at 8 a.m. The exam proctor greeted us with an unfeeling, nonbiased handshake. She began by informing us the SPE would soon be incorporated into medical licensing exam procedures. The program’s cost was the only thing that was keeping it from becoming instituted, and students could pick up most of that cost, she said.
She then explained the logistics. We would read a short description of each case before entering the patient’s room. We would have exactly 15 minutes with each patient, all of whom were professional actors. We were told to focus on the patient’s history and physical exam. The actors would not be grading us, the proctor emphasized. The patients/actors would merely fill out a sheet with bubbles marked “yes” and “no” next to elements of the history and physical exam. They would also fill in bubbles with their impressions of our interpersonal skills. This form would then be passed through a machine that would calculate the results and give us our grade; once again, the proctor emphasized, the actors would not be grading us. A buzzer would sound at exactly 10 minutes. The final buzzer would sound at 15 minutes, at which point we must have concluded the encounter. We were to promptly leave the room; we would not be allowed to re-enter for any reason. The proctor smiled and praised the program for its ability to evaluate the full, functioning physician much better than a paper-and-pencil exam might be able to.
I entered the first room. A middle-aged woman wearing a flower-print patient gown sat with her legs hanging loosely over the edge of the light-blue upholstered exam table. I greeted her with a handshake. “What brings you in today?” I said.
She explained she was having difficulty sleeping. After a few more questions, I learned she was getting up three or four times a night to urinate. I wondered if she was urinating frequently during the day. She answered affirmatively. I began to think about diabetes. I asked if she had noticed any changes in her vision. She hadn’t. I asked about episodes of lightheadedness or loss of sensation. Negative again.
“Anything else going on?” I queried before beginning the physical exam.
“No….” she trailed off.
“Have you lost any weight?”
“Oh, you said, ‘Is anything else going on?’” she said. Apparently that wasn’t on her list of questions. “Yes, I have lost some weight. Five pounds in the past month, in fact.” I went through the physical exam, careful to maneuver the wall-tethered ophthalmoscope cord around her head.
“Good—you didn’t give me the medical-student strangle,” she said. After finishing the exam, I told her I would talk to my attending physician and return to discuss the treatment plan with her. Of course, I was not to re-enter the room under any circumstances, but we both knew that, anyway.
My next patient was in for hypertension counseling. His blood pressure was elevated at a health fair screening, and his wife had been urging him to come in for a checkup. I went through a series of hypertension questions and then jumped into the physical exam. I noticed a white sheet resting on one of the room’s hard-backed red chairs. I figured that was my cue to demonstrate my ability to drape the lower body while pulling the gown up to examine the abdomen. I asked the patient to lie back. I draped the sheet over his legs and pelvis as I skillfully lifted his gown to reveal his abdomen. I began to palpate the right upper quadrant.
“Oh, I’m so uncomfortable,” he moaned loudly. I looked at him quizzically. Had I missed something in the history? Or was this patient suffering from some sort of bizarre hypertensive gall bladder obstruction?
“Do you hurt up here?” I asked, pointing to the right side of his abdomen.
“No, I’m uncomfortable down here,” he blurted, shaking his lower legs. In the midst of draping, I had neglected to extend the leg rest at the lower end of the exam table. I apologized as I pulled the extension under his legs. I finished the exam, hoping my draping ability might counterbalance my failed exam-table-extension technique.
Patient No. 3 was a woman in her early 30s dressed in jeans and a button-down, pink shirt. She looked toward the ground as I extended my hand to greet her. A sea of dark-brown makeup stretched across the upper half of her left cheek. Four long streaks of blue makeup cut across the lower halves of each of her arms. The makeup was meant to represent bruises—the examiners had apparently decided to go just one step short of writing “I am abused” on the wall above the patient’s chair.
I asked the woman about her home situation. She said she wished she could work harder and do more, especially in light of her husband’s recent stresses. She was reluctant to admit her husband was actually abusing her, blaming herself instead for the domestic situation. She insisted I prescribe a sleeping medication. The buzzer sounded at 10 minutes. The patient began to cry. I felt a helpless ache in my heart. I talked to her about returning to see me soon. I mentioned the possibility of counseling and domestic violence resources. The 15-minute buzzer sounded. A hard knock rattled the door. Apparently I had other patients to see, and not even domestic abuse was going to let me stretch out my time limits. I bid the woman a quick farewell and left to push on in my conquest of the day’s slate of outpatient disorders.
Patient No. 4 had been through a morning of medical student torture. He was supposed to have been relieved of his duty, but the replacement actor had failed to show up. As the lone low-back-pain actor, this patient seemed to be suffering more from the pain of seeing his eighth medical student of the day than from the lumbar ache that had supposedly prompted his visit. Once the exam began, I pressed lightly on his spine. He nearly launched himself off the table.
“Oh, that HURTS!” he said. I continued to palpate softly up and down the spine. He moaned with each successive feather-weight compression. I moved my finger to the muscle paralleling his spine and pressed lightly. He moaned again.
“Does that hurt too?” I wondered.
“Oh, no, not really,” he said, catching himself. I pressed on the muscle again, and he sat quietly. I finished the exam amidst his occasional moans and spasm-like gyrations.
I left the room and completed my written summary of patient No. 4. As I wrote, I thought back on the patient encounters of the day. The proctor had praised the exercise as a measure of our effectiveness in a physician–patient interaction. As a patient myself, I thought about some of my encounters with physicians. Much of my trust came when physicians were willing to put aside the 15-minute limit to devote the necessary time to a deserving concern. I wondered if the physician–patient relationship had now been stripped to its essence: a checklist of trigger phrases and exam room rituals.
I thought about the tone of the patient histories and exams. It seemed each patient I had seen that day carried a certain air of combativeness. They reminded me of the few patients with whom I had interacted in actual clinical settings who appeared set on analyzing each move and each question, as if a lawsuit were in the front of their minds. I felt placed in that same sort of setting with the four patients I had seen as part of the SPE—as if the cooperation so necessary in medicine had given way to a game of sorts, a cat-and-mouse chase. The union of patient and physician was lost as the patients/actors smugly concealed the questions students missed and the symptoms they failed to elicit.
The SPE, I concluded, rewards an encounter that covers the elements of a checklist within a 15-minute time limit. Emotion and personal connection are secondary to a collection of required questions and physical exam maneuvers, elements that can be measured and graded objectively. In its attempt to objectively appraise the student’s proficiency in the physician–patient setting, the SPE seems to have dimmed the vision of much of the essence of this relationship: cooperation, confidence and even the bias that comes through a patient’s preference for a certain personality, a certain style and a certain trust that has developed over years of interaction.
Perhaps SPEs play a role in evaluating a student’s proficiency at recalling information and performing physical exam techniques. Participating in this type of evaluation procedure, at least the one proposed by the NBME, will require students to pay an estimated $1,000 to take the exam, and that doesn’t include the costs incurred to travel to select testing locations across the country. Whether performing this recall in front of a trained actor is worth the additional cost over current evaluation procedures seems a question worthy of serious consideration.
Certainly, medical licensing authorities can’t be blamed for their desires to incorporate licensing exams evaluating a physician’s efficacy in a clinical setting. The SPE, on the surface, appears to test a physician’s ability to interact with a patient and establish a comfortable relationship. By promoting this image, the exam implementers seem to appease educators’ desires to demonstrate their interest in physician–patient communication and effective clinical practice.
In its practical use, however, the SPE does little more than add another “hoop” for physicians-in-training to jump through in the process of medical education: an exam for which lists will be crammed, exam room procedures will be memorized and executed with precision, and exam review services will generate additional revenue. When the masks come off on the stage of the SPE, the exam is revealed to be just a test dressed up in physicians’ coats and patients’ gowns with a high price of admission and little evaluation efficacy beyond traditional examination procedures.
Troy Madsen is a fourth-year medical student at Johns Hopkins University.