Gerald O'Malley, DO: Something special

I’ve worked for the National Board of Medical Examiners (NBME) and Educational Commission for Foreign Medical Graduates (ECFMG) as a patient note rater for the last five years.

Every medical student and international medical graduate that wants to train in a U.S. residency program has to take and pass a series of licensure exams, including a Clinical Skills Assessment in which the examinee interacts with an actor in a mock examination room setting and writes a note detailing history, physical, differential diagnosis, and proposed work-up. I, along with about 88 other physicians, get paid to rate about a half million notes every year.

The whole testing process is amazing. Read more
There are five testing centers in major cities throughout the U.S. Students and international medical graduates show up to examine fake patients. All of the patient encounters are incredibly realistic. Some of the actors have been portraying the same patient and the same illness for years and have a very good understanding of how a patient with renal colic or alcoholism or pneumonia or GI bleeding presents. The examinees receive instruction and then have a set amount of time to interview and examine the “patient” and write a comprehensive note.

This is a high stakes test. It’s expensive ($1,050 for U.S. students, $1,200 for international medical graduates), plus travel, lodging, and Pepto-Bismol. The anxiety level in the waiting area of the ECFMG testing center on exam day is palpably high. There is usually a table with bagels and coffee that remain untouched by the examinees as they sit around the room in silence waiting to be called to begin the exam. Each examinee has the look of a long-tailed cat in a roomful of rocking chairs. Given the complexity of the exam, the comprehensive nature of the monitoring, and the necessary integration of technology and human interaction to simulate the doctor-patient interaction, it is really amazing that testing goes so smoothly.

The first time I saw the testing center I remember feeling a certain pride. My wife is an international medical graduate and I’ve been involved in international medical education through my work as a Navy medical officer in Japan. The international medical graduates who come to this country and sit for this test cannot help but be impressed and maybe a little intimidated by the attention that is given to this test and the seriousness that surrounds the whole testing process.

This week, all the patient note raters attended our annual refresher training, which is a four-hour process and like everything else that the ECFMG does, it was highly organized and valuable. We sat in a large room and performed exercises and discussed problems with the rating process and ways to improve quality, accuracy, and reliability of our note rating. We received feedback on the notes that we have rated and we were given details about our statistical scoring averages and ranges and standard deviations and skew and kurtosis (tells something about rating bias - by the way, you don’t want to be too leptokurtotic — too peaked — or platykurtotic — too flat — but more mesokurtotic, in case you we were wondering) with histograms illustrating our rating history.

Some of us have already seen this data in private remediation sessions held with Tom the friendly physician medical director. The oversight and double and triple checking and analysis are endless. Each note is rated several dozen times by several dozen different raters. The first attempt failure rate for U.S. graduate is about 3 percent and for international medical graduates, it’s about 30 percent.

I think that every physician that practices in the U.S. should feel the same sense of pride that this program is run so competently. This is the face that we present to doctors all over the world. The fact that this whole process is so arduous and comprehensive and professionally administered demonstrates to the rest of the world that we take medical education and training very seriously and being a physician in the United States is something special.

Gerald O'Malley, DO, is the director of research in the largest, busiest emergency department in Philadelphia and an associate professor of emergency medicine at Thomas Jefferson University Hospital. He’s also the son of a NYC cop, die-hard Yankees fan, and a regular contributor to Practice Notes.