Rapport with patients gets hard look
Actors trained to fake an illness test West Virginia University
medical students on their bedside manner and ability to diagnose patient
Two years ago, Rebecca Burbridge took the test and learned a
lesson: Stop using complicated medical terms.
“I walked into the room, asked the patient something, and she
had to ask me what I meant,” said Burbridge, now a fourth-year medical
student. “It’s something stupid that you wouldn’t think about. Now, it’s always
in the back of my head.”
Nationally, more medical schools are using a test similar to
the one used at WVU, according to the Federation of State Medical Boards. By
2004, all medical students may have to pass a communication and clinical test
with standardized patients before they get their license.
One of the reasons behind the test cuts to the heart of the
medical malpractice debate: A doctor’s ability to form a rapport with a patient
can be the defining line between a person filing a lawsuit or not suing a
doctor when something goes wrong.
“A lawyer once told me about the No. 1 defense to getting
sued,” said Dr. Michelle Nuss, assistant professor of medicine and psychiatry
at WVU. “If the patient likes you and you screw up, they’ll be less likely to
Medical students are book smart, but can they communicate with
their patients? That was one of WVU’s goals when it first made students take
the Objective Structured Clinical Examination four years ago, said Nuss, one of
two WVU professors teaching the yearlong class.
“It can be a disaster,” Nuss said. “Some students just don’t
have the social and communication skills to do effective medicine.”
Marshall University uses a similar evaluation on its students.
The West Virginia School of Osteopathic Medicine hopes to start the test in the
next several months, said Dr. Howard Hunt, the osteopathic school’s associate
dean for clinical education.
‘A desire to seek retribution’
Not all victims of medical negligence sue. And not all
malpractice lawsuits result from doctor negligence.
So what makes some patients sue when something goes wrong when
others may not?
Four University of Rochester doctors tackled this question,
wading through 45 plaintiffs’ depositions from settled malpractice suits from
Here are some of the findings of their June 1994 Archives of
Internal Medicine article:
provider in 71 percent of the cases.
percent of the suits. Patients may have had trouble contacting their doctor, or
the physician sent a surrogate — usually a medical resident — to deal with the
patient. This is the most common relationship complaint, the study said.
patient’s symptom or the opinion of the family or patient.
“When the observations and opinions of patients or their
families are summarily rejected ... and then their opinions subsequently turns
out to be correct, their initial anger can evolve into a desire to seek
retribution,” the report said.
But a year later, an Archives of Internal Medicine commentary
challenged the results.
“Someone who is angry at a health professional or feels that he
or she has been wronged or injured, may tend to view the doctor-patient
relationship less sympathetically than they had at the time of the initial
encounter,” the column states.
According to the June 1994 issue of Lancet, a group of British
doctors found similar results after interviewing 227 patients and relatives who
had sued their doctor.
More than 60 percent said the doctor gave them inaccurate or
unclear explanations when something went wrong.
“Patients often blame doctors not so much for the original
mistake, as for a lack of openness or willingness to explain,” said the authors
of “Why do people sue doctors?”
A June 2002 report in the Journal of the American Medical
Association added: “Patients who saw physicians with the highest number of
lawsuits were more likely to complain that their physicians would not listen or
return telephone calls, were rude and did not show respect.”
The cultural divide
But if communication is one of the reasons behind malpractice
cases, as suggested by several studies in peer-reviewed medical journals, what
about the plethora of doctors treating patients in West Virginia who trained
outside the country in another culture?
The J-1 visa program supplies West Virginia’s medically
underserved population with doctors. The program allows foreign medical
residents to stay in the United States after their training is complete if they
promise to work in a medically underserved area.
About 30 percent of West Virginia doctors are foreign-trained,
said Dr. Ahmed Faheem, a Beckley psychiatrist and member of the state Board of
Medicine’s complaint committee. About the same percentage of internationally
trained physicians work at CAMC, said Andy Wessels, spokesman.
But many of West Virginia’s doctors who trained in another
country came from the Philippines, India or Pakistan, where they trained under
a British model that focuses a lot more on patient interaction, said Faheem,
former president of the West Virginia State Medical Association.
Faheem, who trained in India, recalled a professor telling him
that he should have a good idea of what was wrong with a patient by just
watching them enter the room. Doctors abroad, he said, rely more on their
observations from listening and looking at a patient instead of a lot of
laboratory or specialized tests.
This is partially due to the limited resources available under
Britain’s national health system, Faheem said
“Several patients [here] have said they feel they get more
attention and more time from people from abroad as compared to locally trained
doctors,” he added.
In 1987, the U.S. General Accounting Office looked at 31,395
malpractice claims and found that foreign-trained doctors were not more likely
to be sued than U.S. medical graduates.
In West Virginia, about 38 percent of Kanawha County doctors
sued for malpractice from 1993 to 2000 went to medical school abroad. But they
were responsible for about half of all awards — about $20 million, according to
board of medicine records on damage awards reported by insurance
A lot of the Kanawha County specialists are more at risk of
getting sued because they perform more complicated procedures trained in
another country, Faheem said.
In 1998, for example, about 70 percent of the heart surgeons at
CAMC did not train in the United States, along with about one-third of its
neurosurgeons and general surgeons, according to a 1998 CAMC directory. But
U.S.-trained doctors made up most of the orthopedic surgeons and
obstetricians/gynecologists working at CAMC.
“But unless there’s a language barrier, I don’t see why or how
a foreign-trained physician would be lacking with his bedside manners or with
appropriate interaction with the patients,” Faheem said.
Foreign doctors already face more obstacles to getting a
medical license in America. Unlike their American counterparts, internationally
trained doctors already have to pass a communication and clinical test with
standardized patients, among other added requirements, he said.
Dr. Henry Taylor, the public health education program director
for West Virginia’s Higher Education Policy Commission, authored a study that
compared the number of lawsuits against foreign-trained doctors to physicians
who studied in the United States.
Taylor, former state public health officer and secretary of the
board of medicine, could not produce a copy of the report. But he said there
was no difference between the quality of those doctors.
“On the surface, it makes sense,” Taylor said. “But it seems to
depend more on the doctor’s training and personality characteristics rather
than their country of origin.”
Provoking fear and secrecy
Teaching students better communication skills may make them
better doctors, but it won’t decrease the number of medical malpractice cases,
said Dr. Roberto Kusminsky, a Charleston surgeon.
“Teaching better behavior will not solve the problem of
malpractice,” he said. “It may decrease the triggering mechanism — but it’s not
Instead, Kusminsky referred to reports by the National Academy
of Science’s Institute of Medicine, an independent body that advises the
federal government on technological and scientific issues.
“Blame-worthy clinicians” aren’t to blame for a majority of
lawsuits, according to the “To Err is Human” report. Problems result from an
inadequate health-care system, which relies too much on handwriting, human
memory, poor communication systems and not enough understanding of the
consequences of fatigue, according to the report.
The entire system needs to be reorganized. Because doctors fear
lawsuits, they are too reluctant to report problems — even when it isn’t their
“This requires rare breeds of courage or foolhardiness in a
legal climate that provokes fear and secrecy,” according to the
The institute suggested a no-fault compensation system for
patients who are injured by doctors or hospitals. A state or region could start
a pilot project that gave patients an option to waive their right to a trial by
jury when they joined a health plan or entered a hospital, according to the
When something goes awry, an independent panel could quickly
compensate the victim and judge whether the doctor gave substandard care.
Doctors who participated could pay lower malpractice premiums
if they agreed to immediately report any problems that occurred.
Solving the problem?
Lawmakers in West Virginia and nationwide are debating the
merits of “tort reform,” or limits on medical malpractice lawsuits, as a way to
slow the growth of doctors’ malpractice insurance premiums.
Dr. James N. Thompson, executive vice president and CEO of the
Federation of State Medical Boards, said he hopes testing medical students on
their communication and clinical skills will tag future doctors who need more
He also hopes the test will prove to the legal community that
doctors are doing their part to reduce malpractice cases.
“I think the profession is fulfilling its responsibility to be
accountable to the public,” said Thompson, former dean at the Wake Forest
University School of Medicine and former member of the national License
Committee on Medical Education. “Maybe attorneys who defend patients will look
upon us in greater favor and use this as an opportunity to push for tort
According to an analysis by the Gazette-Mail, however, lawsuits
may have nothing to do with costly malpractice premiums. The number of claims
against the state’s doctors since 1993 has decreased and the amount of money
spent to settle the claims has not changed, according to board of medicine
To contact staff writer Joy Davia, use e-mail or call 348-