Validation of the doctor-patient communication component of the Educational Commission for Foreign Medical Graduates Clinical Skills Assessment

BACKGROUND: The pivotal role of doctor-patient communication in effective health care delivery led the Educational Commission for Foreign Medical Graduates (ECFMG) to incorporate the assessment of interpersonal skills and spoken English proficiency into its Clinical Skills Assessment (CSA). Furthermore, it was decided that to pass the CSA, a candidate would need to meet or surpass defined performance standards for doctor-patient communication as a discrete component. This requirement, among others, is designed to ensure the readiness of graduates of foreign medical schools (FMGs) to enter postgraduate medical education programmes in the United States. OBJECTIVE: The primary focus of this study was to determine the extent to which performance in a simulated testing environment is related to performance in the clinical setting. METHOD: Nurses were trained to rate the communication skills of residents from the patient's perspective. A total of 43 first-year residents were evaluated. The survey ratings (n=225) were compared with the residents' CSA communication scores. RESULTS: Corrected correlations between CSA ratings and those obtained from nurses ranged from 0.61 to 0.73. CONCLUSION: This study provides evidence for the validity of the communication ratings provided by standardized patients. The reasonably strong associations between ratings obtained during testing and those obtained through observation of 'real' patient interactions suggest that external observers can provide accurate evaluations of doctor-patient communication.     

The underrepresented in graduate medical education and medical research

There is a perception that the career options open to medical school graduates who are members of minority groups are restricted. This perception relates especially to those postgraduate medical training programs that have not traditionally encouraged or had significant minority participation. Data were therefore sought to determine whether this perception was well founded. Recent reports show the strikingly low numbers of minorities on medical school faculties and in administrative positions in spite of efforts to fill such positions. Information on the specialties of practicing minority physicians is limited, but accurate figures are available on the participation of minorities in various specialty postgraduate training programs. For instance, during recent years, 50 to 60 percent of all black residents have been trained in internal medicine, pediatrics, general surgery, and obstetrics and gynecology. Further studies are needed to document or disprove the conception that minority physicians have less access than other physicians to certain careers in the delivery of health care and education. In the interim, efforts should be continued to encourage minority physicians not only to seek preparation for community primary care practice, but also for professional participation in academic careers of other specialties (and subspecialties), in biomedical and clinical research, and in health care administration. The ability to enter these diverse careers is most often determined by the opportunities available at the time of completion of medical school education. Therefore, those involved in graduate medical education should address the challenge of providing opportunities for the proportionate representation of minorities in all aspects of medical care and medical education.     

Plagiarism in graduate medical education

The act of overt plagiarism by graduates of accredited residency programs represents a failure in personal integrity. It also indicates a lack of professionalism, one of the six Accreditation Council for Graduate Medical Education (ACGME) competencies for graduate medical education. A recent experience at one geriatric fellowship indicates that the problem of plagiarism may be more prevalent than previously recognized. A situation was discovered at the geriatric medicine fellowship at Florida Hospital Family Medicine Residency Program in Orlando, Fla, in which three of the personal statements included in a total of 26 applications to the fellowship in the past 2 years contained portions plagiarized from a single Web site. The aim in documenting this plagiarism is to raise awareness among medical educators about the availability of online sources of content and ease of electronic plagiarism. Some students and residents may not recognize copying other resources verbatim as plagiarism. Residency programs should evaluate their own need for education about plagiarism and include this in the training of the competency of professionalism.     

Nutrition Academic Award: nutrition education in graduate medical education

The Nutrition Academic Award received by Tufts University School of Medicine strengthened our first-year Nutrition and Medicine course and clearly resulted in more nutrition in third-year clerkships and residency programs. Standardized patient cases in nutrition counseling for cardiovascular disease and weight loss were developed and incorporated into the clerkships and residency programs in internal medicine and family medicine. This was a value-added benefit that provided practice in initiating lifestyle changes and motivational skills, while expanding nutrition education. Eight standardized patient educators were trained in collaboration with physicians in internal and family medicine. Six slide shows on nutrition topics, 1-2 h each, were developed and included clinical cases, dietary analysis, and patient handouts. The Medicine Clerkship included 4 nutrition sessions and the standardized patient experience, whereas the Family Medicine Clerkship included 1 nutrition session and the standardized patient experience. Working with faculty in the Department of Family Medicine, we developed a nutrition mentoring program for the family medicine residents and used 3 nutrition messages that were a modification of the Dietary Approaches to Stop Hypertension (DASH) diet to teach diet evaluation, intervention strategies, feedback from nutrition referrals, and follow-up. Seven sessions on nutrition and chronic disease with cases were offered to the residents in family medicine, which concluded with a nutrition intervention session using standardized patient educators. This expanded nutrition program in internal and family medicine along with the standardized patient experience receives excellent ratings from physicians, residents, and medical students.     

Financing graduate medical education in primary care: options for change

The current mechanisms of graduate medical education (GME) financing favor inpatient and procedural care, making the support of primary care programs difficult, as these residencies are oriented toward outpatient evaluation and management. Criteria for evaluating proposals that aim to improve the financial support of primary care programs include the financial, administrative, and educational implications of the options as well as the views of interested stakeholders. Other sources of funding for primary care GME are changes in existing Medicare payments; increased categorical GME funding, ambulatory payment, and grants; commitments from future employers; and redistribution of current funds. Alternatives for spending these funds to aid primary care programs include dividing the sources in three ways: on a per-resident basis, by competitive grants, or by incentives for primary care education. An analysis of the alternatives for changing GME financing shows that several solutions will be needed simultaneously.     

Paying for graduate medical education: the debate goes on

The debate over Medicare payments for graduate medical education has been conducted under the premise that such payments cover the added costs of training. Standard economic theory suggests that residents bear the costs of their training, implying that the additional costs of teaching hospitals are not attributable to training per se but to some combination of a different patient care product, unmeasured case-mix differences, and the costs of clinical research. As a result, payment for the additional patient care costs at teaching hospitals should come from the Medicare trust fund; any subsidies for training should come from general revenues.     

Medicaid's role in financing graduate medical education

Medicaid is the second-largest explicit payer of graduate medical education (GME). All but five states pay for GME ($2.4 billion in 1998). As states rapidly move their Medicaid populations to managed care, Medicaid support for GME is subject to change. Just sixteen states and the District of Columbia carve out Medicaid GME payments from capitated rates to managed care plans and rechannel them to teaching programs. Concurrently, managed care has motivated several states to distribute Medicaid GME funds in ways more explicitly accountable to the public. Ten states require that GME payments be directly linked to state policy goals intended to vary the distribution of or limit the health care workforce.     

A global strategy for medical education: partners in reform

Summary. The onrush of beneficial change which now flows in medical education has never been stronger since the start of this century. Such activity has not been seen since the era of Flexner. There can be no doubt that the world scene is now set for decisive, effective action. The many tributaries of the stream of reform converge this year at Edinburgh, to diverge again into six Regional Conferences during 1994 in Africa, the Americas, the Eastern Mediterranean, Europe, South-East Asia and the Western Pacific. The centres of activity and connection cited below do not in any way make up a comprehensive catalogue. Rather, each development and each reform is a link in a chain, a module with which the World Federation for Medical Education (WFME) has been implicated. Each name given, each title stated, is intended as a marker, a nexus. These are among the partners to be mobilized and brought together for the task.