A Tale of Two Inquiries (or, Doing Being Competent in a Clinical Skills Exam)

Abstract

Phenomenon: In high-stakes evaluations of communicative competency, data-gathering skills are commonly assessed through the use of standardized patient encounters. This article seeks to document inquiry practices in 2 such encounters in a setting designed to emulate a consequential, clinical skills examination. Approach: Drawing on the methods and findings of Conversation Analysis, we examine selected fragments seeking to understand how, in the ways in which they are organized, they produce quite different outcomes. Findings: In the first encounter, the topic of the patient's history of depression arises naturally in the course of the interview. It happens to be a checklist item for the case and the examinee receives credit for having elicited it. In the second encounter, though the examinee was the more clinically experienced, the topic does not come up and the examinee fails to receive credit. Insights: When we examine how the two inquiry sequences develop on a turn-by-turn basis, it becomes clear that the differences between inquiry practices that carefully constrain patient responses and those that leave space for patient elaboration are subtle but evident. Both types of practice, however, are presumably a part of competent clinical performance. We argue that looking carefully at how specific interactional practices operate within clinical interviews can enable us to become more articulate as to what might count as communicative competence in the clinic.

Keywords:

• standardized patients
• USMLE Step 2 CS
• communicative competence

Notes

* SCRIHS (Springfield Committee for Research Involving Human Subjects) Protocol #06-126.

* Yet another policy can be seen in the structure of the USMLE Step 2-CS. The Spoken English Proficiency score, which is independent from the CIS score,⁵ reflects a policy that all U.S. medical practitioners be fluent in English.

Additional information

Funding

This project was funded under a grant from the National Institute of Mental Health, Division of Services and Intervention Research (DSIR) [#5R03MH74979, 12/1/06-11/31/09].