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In Search of Marcus Welby: Is a “People Skills Test” Really Going to Find Us Better Doctors?

This week the NY Times favorably reported: “New for Aspiring Doctors, the People Skills Test.” It goes like this:  Present a brief, but challenging, medical ethical scenario to medical school applicants. Allow 2 minutes to synthesize and respond. Sit down and discuss conundrum with trained examiner—could be a professor of medicine or a community business leader. Repeat with a new scenario about a dozen times in a few hours.
Recipe for success? They claim this new test identifies thoughtful, caring, team players. Really? To me it sounds like a great way for the articulate/glib talker/fast thinker to talk him/herself into or out of a medical career, depending on the political, social, moral or medical point of view of the interviewers. Citing the high score correlation to passing licensing test (all based on multiple choice) does little to convince me otherwise.

No doubt communication skills are important, but “testing for competency” in the variety of settings in which physicians communicate is totally lost in this marathon talk-a-thon. One size does not fit all. Conversations with colleagues sound nothing like my office hours with parents and children where communication often takes the form of play. Medical records communications, particularly “orders” for nurses to implement, require a different set of communication skills.

Communicating during a cardio-pulmonary arrest or a difficult surgery where quick thinking and directing many people into simultaneous team action are require by a team, requires a physician who must speak strongly and authoritatively. And few to no words are often best after delivering a difficult diagnosis where body language and hand holding can say it all.

Can it really be true that future doctors are flawed because they are bad commuicators? And do these people them become “bad, sometimes obnoxious” doctors because they might think, act and speak differently? I more likely scenario is that these idealistic newbies learn communication behaviors during medical school and residency training. Rigid and hierarchical, didactic as opposed to interactive, meaningful communication has been subsumed into a culture of demeaning the lowest on the totem pole (called pimping) and let’s just get the work done (i.e. run the scut list) on time to meet resident work hour rules.

In this new game, the slow, methodical thinker, the man who must mull over the conversation, the women who has deeply help religious beliefs that might be shared by her patients (but not her examiners), and the quiet but extraordinarily brilliant future physician scientist will all be left out, left behind. This will spell disaster for what should be a diversely talented physician workforce. Strengths are built through differences.

Team Player or Team Leader?

Is being a team player really is a desirable quality for a physician? Maybe sometimes, but not usually. Note the subtle, but important, distinction between ‘team player’ and ‘team leader.’ Physicians must be team leaders. Ask the tough and answer questions, challenge and change the prevailing “wisdom,” and assume the ultimate responsibility for each and every patient that walks through the door. On my first clinical rotation Professor of OB-GYN, Dr. Dorothy Barbo, spent our first few hours together inculcating us with how sacred the trust we were given to care for, to respect, and to listen to our patients.

Simply put, medicine is not practiced by committee. Ultimately the singular relationship between a doctor and a patient is where it takes place. Developed on trust and caring, a physician personally takes personal responsibility. Without this commitment, very bad outcomes occur because he or she abrogates their responsibilities to consensus thinking that defies “personalized” medicine—caring for and about one unique human being by another unique, highly trained human being.

Nothing wrong with teams for improving systems and building programs, but the best care for the individual comes from doctors who learn to lead and bring about extraordinary change, something that is getting more difficulty during a time of “different is disruptive.”

The solution? Every physician goes to medical school and trains in a residency training program. During these formative years, medical schools must respond to the undeniable need to change the culture and instill commitment—to caring, mutual respect, and appropriate communications. As medical educators and future colleague we must take the responsibility off the many talented men and women who are not going to be identified by speed “dating” type interviews to test skills that are multi-faceted and cannot be simplified to a series of brief conversations which favor the well-read rather than the well thought out.

Take heart, would be applicants. The Princeton Review and Stanley Kaplan, I am sure, are already on their way to designing prep courses to help you through this new hoop you will need to jump through. Learn the right answers, the right style, and the right buzz words, and you will do just fine. Meanwhile, it’s time the rest of us faced our challenges from within.

3 Notes

  1. Dr. Maharam,I’ve read your post a couple of times and I still don’t udtnrseand what points you were trying to make. The post gives the impression that there is some great conflict in the medical community with much of the debate touching on issues that laymen don’t have good perspectives on.The fact of the matter is that even when laymen try to be engaged patients, over the short to medium term, we are generally unqualified to judge the quality of the medical care we receive, let alone the quality of the medical personnel. We are forced to trust that there is a system that ensures adequate quality. We might be qualified to judge the bedside manner of the doctor. But, maybe there is a poor correlation between bedside manner care quality.Several times I experienced situations where a doctor has given a very rational explanation of their diagnosis and recommended treatment only to have a new data arrive, or a different doctor get involved, and the diagnosis treatment radically change. Both explanations sounded very reasonable to me, yet they presented completely different versions of reality. This type of experience has convinced me that medical care is really, really complicated I’m unqualified to self diagnose or treat.Regarding PAs, etc, I certainly udtnrseand the argument that PAs can provide adequate care. But, like most laymen, I don’t have the perspective to judge if this works in reality.When I read recommendations , like yours, to have a primary care physician, I don’t think this is a recommendation to have a PA, so I look for a physician.

  2. Patients do need to be aware that physicians have far more tinanirg and experience than PA’s and NP’s, and that is why they must practice under the supervision of an attending physician. As with doctors, there are good PA’s and NP’s and there are bad ones. PA’s in Illinois I believe have 2 years of tinanirg after a 4 year college Bachelor’s degree. Primary care physicians have 4 years of med school and at least 3 years of residency (7 years total) after college, and are much better at inpatient patient care than PA’s and NP’s.In my former practice, I let the PA handle relatively simple and/or acute illnesses when my schedule was booked. I am more hands-on than most physicians, so I really preferred to do the physicals, chronic disease management, preventive health care, and handle the tougher issues myself. This came in very handy if patients had to be hospitalized because I already knew their case rather than just depending on the PA. Of course, one problem with this was burn-out and lack of financial compensation given the ridiculous reimbursement system is this country. Primary care physicians are not rewarded for doing a good job, but certainly pay the price in malpractice when they do a bad job. Another upsetting situation was that our largest HMO (30% of total business) financially penalized me for spending too much money, despite having the very highest rates of keeping patients up to date with their preventive health care (e.g. mammograms, colonoscopies, immunizations, stress tests when indicated, etc.) which costs time and money. No good deed goes unpunished. One thing is certain there is a shortage of PCP’s (and RN’s)in this country, especially in rural areas. PA’s and NP’s can partially fill the void, but health care in this country will continue to decline unless major reform of the health care system is undertaken.

  3. very good points. the team learning should be part of the training and one-off superficial encounters will not necessarily identify (or weed out) those most/least appropriate for team settings. the NYT article mentions that the only ‘new’ stuff happens in the first 5 minutes of the interview, but i found that was when we finally broke the ice and got past the performance BS. sounds like speed interviewing will isolate the pure BS. it makes some sense, though, but it should be integrated with old methods, not replace them.

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