Test for better bedside manner fulfills Melnick's mission.

IN THIS ARTICLE ...

Meet Donald Melnick, MD, FACPE, the force behind the new doctor/patient communication test that begins this summer as part of the National Board of Medical Examiners' licensing requirements.

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Growing up in the small town of Elmira, N.Y., Donald E. Melnick knew by the age of 4 that he wanted to be a doctor. It might have been early for a career choice, but he already had three good role models in the field.

One was his mother, a nurse who often took her four children to her hospital job on school days off, and taught them games naming bones of the body.

Another was "Doctor Dan, The Bandage Man"--the star of a Little Golden Book that served as an early marketing tool for Band-Aids--who excelled at applying bandages to the imaginary wounds of dolls.

The third was a family doctor who made house calls, a fatherly man whose care for his patients was evident in the worst of times. When Melnick's mother died young, the doctor came by. She had died from a test to determine the extent of her brain cancer. Though he was not the physician who had performed the procedure, the family doctor sat down and explained why it had happened, in terms the 11-year-old Melnick could understand. He offered consolation, too.

When that family doctor died himself, years later--after three of the four Melnick children had chosen health professions--his wife sent Melnick his mother's medical records.

"Just in looking at his chart notes from whatever year it was, 1960 or 61, when she died, that sort of attention to the patient came through even in the chart notes that were written, in the anecdotes," Melnick says. "I still remember that part of it as an example of a doctor making the human connection with the family."

No dumb doctors

Now Melnick, 55, is president of the National Board of Medical Examiners, the driving force behind a new licensing test to measure the way physicians communicate with patients that has stirred both excitement and opposition. When he talks about the reasons for the exam--and for his involvement in the field of testing--Melnick thinks back to that family doctor.

"I think most patients presume knowledge and skill competence; that's a given." Melnick says. "You don't want a dumb doctor. You don't want a surgeon who doesn't know how to use a scalpel. You assume that. But where your expectations really start from that foundation is on how a doctor relates to you as a patient."

The Clinical Skills Exam, being given for the first time this summer, requires prospective doctors to travel to testing sites in Atlanta, Chicago, Houston, Los Angeles and Philadelphia. There, they walk into what looks like a medical clinic, don white coats and meet with 12 patients, each waiting in an examining room with information about their case on the door.

After each 15-minute consultation, the "patient" will rate how well the doctor communicated, as the doctor writes a patient note outside. The evaluations count as part of Step 2 on the U.S. Medical Licensing Examination, the test every doctor must pass before he is licensed to practice. The test is co-sponsored by the Federation of State Medical Boards.

The test has been heralded by patient polls and some medical educators, but also has had powerful critics, including the American Medical Association. The cost of the test, the need to travel to testing sites, and the idea of measuring the seemingly subjective judgment of a physician's bedside manner have drawn some fire.

But friends and associates say if there's a poster leader for the test, it's Melnick.

"Away from work, you see how his high purpose sort of extends into the rest of his life," says W.T. Williams Jr., a retired internist and pediatrician in Davidson, N.C., who has known Melnick for about 15 years as a member of the NBME board. "He's a very dedicated family person, very dedicated husband and father and deeply committed to his spiritual values ... He certainly lives that high ethical standard. He doesn't expect anything of anybody that he's not expecting of himself."

Says Ruth Hoppe, vice-chair of NBME's board and a retired professor at Michigan State University's College of Human Medicine: "He is clearly one of the top people nationally in the field of assessment of health professionals. He brings experience, integrity and willingness to work very hard to all that he does."

'Leave It to Beaver' childhood

That simple belief in the human connection--some might call it old-fashioned--had its roots in Elmira, in an upbringing Melnick described as "Leave It to Beaver," with extended family and supportive neighbors all around. His father was a mechanic for an auto dealership and several aunts were teachers.

He attended Columbia Union College in Takoma Park, Md., because of its affiliation with the Seventh--Day Adventist Church. He fell in love with a student there, Pamela Raupach, and they married a year after his graduation in 1971. A piano teacher and stay-at-home mother while they were raising their two children. Pamela Melnick later became a marriage and family therapist.

While Melnick had chosen his path into medicine early, he still yearned to see something of the world. In addition to chemistry, he chose German as a second undergraduate major so that he could spend his sophomore year abroad. He borrowed a Volkswagen camper with a group of friends and traveled around Eastern Europe, trying to avoid looking too American at the height of the Vietnam War.

After completing his medical degree at Loma Linda University. Melnick had an unexpected bit of time on his hands. Medical schools were being pressured to churn out students in just three years to ease a shortage of doctors, so he graduated nearly a year before internships began. He won a fellowship to learn about medicine in the Third World, and found himself helping at an Adventist hospital in downtown Saigon just a few months before the city fell. When it became too dangerous to stay, he and his wife finished the fellowship in Malaysia.

He treated war-related injuries and exotic diseases he would never see again. But most of all, Melnick was struck by the parade of everyday maladies. "I think one of the things that was really impressive was just the day-to-day needs of people medically aren't very much changed by the fact that they're in the middle of a war," he says. "From a distance, if you think about Iraq or Afghanistan or anywhere else, my thoughts always go immediately to how are people doing their grocery shopping and feeding their families and going to the doctor for their high blood pressure or whatever."

Melnick returned home to an internship and residency at the University of Vermont, where he was drawn to the work of Lawrence Weed, pioneer of something called "The Problem-Oriented Medical Record." Weed used medical records as a base for developing computerized systems to make sure doctors didn't skip steps. Melnick used the approach while he was the student medical director for a free clinic run by the school.

With internal medicine as a specialty. Melnick planned to join a practice. But a mentor offered him a faculty position at Marshall University School of Medicine in Huntington, W.Va. He became chief of the general internal medicine section and started an ambulatory care center that he ran for five years.

Systems thinking

It dawned on him that an administrative position in medicine would be the ideal job, channeling most effectively his interest in systems.

At the same time, Melnick began to observe first-hand the roots of less-than-stellar care. "If patients had problems, it probably wasn't because residents didn't know how to oscillate the heart," he says. "It was because the residents didn't know how to talk to the patient."

He also performed reviews on some problem-plagued hospitals for the West Virginia Medical Institute. He would find in some hospitals that five to 10 deaths in 100 were unnecessary, "and there were no systems in place that were really catching it."

In 1983, Melnick--looking to move his family closer to relatives in Elmira and Washington, D.C.--set his sights on the medical schools of Philadelphia. While he was mulling over the opportunities they offered, he answered an ad to work on a computer research project at the National Board of Medical Examiners in Philadelphia--for only a year or two, he thought.

He never left.

"As that project came to an end, the board asked me to take on something else, and then something else, and that was 20 years ago," he says. He became president in 2000.

While NBME wasn't well known, Melnick considered its influence key. Where else than in the licensing examination it designed is there a clearer statement of what we really value? he asks.

Almost as soon as he came on board at NBME, Melnick was asked to help develop a new way to measure a doctor's way of communicating with patients.

As long ago as 1916, the examination included a test of "bedside manners," where prospective physicians took histories and performed physicals on three live patients, then took an oral examination about what they found. But the test did not hold up: the same person would receive very different scores when tested repeatedly, for example. In 1964, the test was dropped.

But NBME's governing board still believed it was worthwhile to measure the seemingly ineffable qualities of caring about patients. From the late 1960s to the mid-1980s, the test incorporated a vignette about a fictitious patient, asking the examinee to choose questions to ask and tests to order.

But this measurement had problems, too: it rewarded the test-taker for following as many avenues of disease as possible, its results were more reflective of the examinee's personality--compulsive types looked better--than of his skills with patients.

Meanwhile, a neurologist named Howard Barrows, now an emeritus professor at Southern Illinois University School of Medicine, developed a program to simulate interactions between patients and medical students. By 2003, 82 of 126 U.S. medical schools instituted some form of the testing and 53 required a passing score for graduation.

NBME officials were intrigued with the idea, but dropped it after some preliminary research. In 1983, a governance committee revisited the notion. When Melnick became senior vice president for research and development in 1987, "standardized patients" became a primary focus.

Drawing on his earlier work with Weed in Vermont, Melnick thought it was important for the licensing system to send a message about doctor-patient relations in its test.

Fake congeniality?

Some powerful opponents disagree. After supporting the concept of the exam, the American Medical Association adopted a policy stating that doctor-patient communications testing should be done by medical schools, not the licensing examination.

Nancy Nielsen, an AMA trustee, said the exam as currently designed doesn't help those who don't pass to improve. Medical schools, she said, can work with students who perform poorly on their communication skills.

Melnick says the AMA's stance doesn't fit our system."

"There are many countries in which medical schools determine whether you are fit to be a doctor," he adds. "Our country did not choose that path ... There's a huge variability in the way medical education is undertaken."

Stephen B. Leapman, executive associate dean for educational affairs at Indiana University School of Medicine, agrees with using the examination for licensing, even though his school has offered simulated patient testing for years. "In spades, I think we should be doing it," he ways.

Others argue the test is too expensive. Doctors who don't live near the five testing sites--Melnick estimates that's a third to 1/2 of all examinees--will have to pay to travel there. The test costs $975.

And if laypeople can pretend to be patients, can't doctors fake congeniality?

Melnick says research shows "you can't learn to be nice for a day." He points out that the cost of the exam pales in comparison with the recent tuition increases medical students have had to shoulder. In all, he said, the testing system he has devoted two decades to implementing promises to change the profession for the better.

Melnick's workmanlike dedication to accomplishing goals extends to personal hobbies. He is steadfastly working his way through a leather-bound collection of 100 "Greatest Books of the Western World," an anniversary gift from his wife. Other times, he's likely to be reading science fiction or leadership theory.

Melnick describes himself as a dedicated Adventist, serving on the board of trustees of Columbia Union College and of the Adventist WholeHealth Network, an organization that promotes wellness programs in Reading, Pa. But he admits struggling to follow some church tenets, such as getting enough exercise. With a typical workday of 10 hours and frequent travel to conferences, "it is one of the challenges: How do you find time to take care of yourself?"

Melnick does take time to be a handyman around his Media, Pa., home, and to be active in the church he and his wife attend. "He can fix and repair most anything," says his friend Williams.

The Melnicks' children are now married and both live in Virginia. Rebekah, 28, teaches high school English and Christopher, 26, develops software.

While the Clinical Skills Exam marks a major accomplishment in his view. Melnick hopes still more changes to physician assessment are in store. He wants to use data gathered during the new exam to find out whether characteristics like the age or gender of patients plays a role in their treatment. And he hopes to find ways to measure and encourage what he calls "professionalism"--honesty, integrity, and avoiding conflicts of interest.

"If we don't test on these things," he says, "we're inadvertently giving a message to students that it's not valuable."

RELATED ARTICLE: Donald E. Melnick

Age: 55. Married with two grown children. Lives in Media, Pa.

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Current positions:

* President, National Board of Medical Examiners, Philadelphia

* Member, Board of Directors, American College of Physician Executives

* Member, Board of Trustees, Columbia Union College, Takoma Park, Md.

* Member, Board of Trustees, Adventist WholeHealth Network, Reading, Pa.

Education:

* Bachelor's degree in chemistry and German, Columbia Union College, 1971

* Doctor of Medicine, Loma Linda University, 1975

* Medical Assistance Program Fellowship, Experience in Third World Medicine, 1974-1975

* Internship in Internal Medicine, Medical Center Hospital of Vermont, University of Vermont, 1976-1978.

Hobbies: Reading, home repair, leading congregational choir.

On his career: "The people who stood out to me as mentors during both medical school and residency tended to be not sort of the highest tech, most skilled subspecialty surgeons, but rather somebody who just showed that they cared, could talk to patients and were loved by patients. That focus on the human side of medicine has always been something that made a doctor stand out as an example to me."

Kate Shatzkin is a staff writer for The Baltimore Sun newspaper in Baltimore, Md.