Letters to the editor

Physician Executive, Sept-Oct, 2004 by Earl R. Washburn

Dear Editor,

Kate Shatzkin's profile of Donald E. Melnick, MD, FACPE (The Physician Executive, 30(4) July/August 2004) convinces me that Dr. Melnick is bright, religious and sincere. I'm not convinced, however, that his effort to push implementation of the Clinical Skills Examination is well considered or appropriate.

The article notes that the American Medical Association adopted a policy statement opposing this exam. As an AMA delegate assigned to the reference committee that considered this issue, I was there for the full deliberation. I didn't have an opinion about the Clinical Skills Exam before the testimony was taken, but afterward I was convinced that this test is not ready for general application.

The main objection to the Clinical Skills Exam came from our AMA student delegates. They objected to the high cost (something Dr. Melnick mostly dismisses as insignificant.) The students rightly argued that the limited number of testing sites is also a huge burden for many. I can tell you that these concerns are important to our medical students, who already carry heavy debt burdens.

More significantly, the students and other delegates objected that the Clinical Skills Exam has not been shown to actually improve the quality of care given by our young doctors. Perhaps it will, but this is still a theoretical construct. Any graduating medical student who fails this exam will not be able to enter residency; how is this to be handled? No one could say. This could hurt many training programs.

Moreover, such a subjective examination has a much higher chance for inadvertent bias, which worries minority students greatly. Most medical boards have dispensed with oral exams for this very reason.

The AMA opposition to the Clinical Skills Exam was based on extensive testimony from both proponents and opponents of the test. The final AMA policy was based on carefully considered arguments and especially the concerns of the affected medical students.

Many see this test as another way in which the National Board of Medical Examiners can make itself ever more necessary. How long before all of us in practice will be required to take a clinical skills exam every few years? I'm sure we could do this and pass, but I'm not convinced that medicine will be any better for all the effort and the cost.

Earl R. Washburn, MD

AMA Delegate

Placerville, CA