ECADES OF RESEARCH HAVEconfirmed that poor skills in patient communication are associated with lower levels of patient satisfaction, higher rates of complaints, an increased risk of malpractice claims, and poorer health outcomes. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Medical schools have responded by incorporating training in patient communication and clinical skills into the curriculum. However, these skills were not systematically evaluated, nor was a minimum level of proficiency required for medical licensure. 17 To address this problem, licensure reforms were undertaken in North America. 18 The Medical Council of Canada (MCC) (1993), 19 the Educational Commission for Foreign Medical Graduates (1998), 20 and most recently the United States Medical Licensing Examination (USMLE) ( 2004) 21 have all introduced a clinical skills examination (CSE)-a nationally standardized assessment of patient-physician communication, clinical history taking, and examination skills-as a requirement for licensure. All US and Canadian medical For editorial comment see p 1057.

Background: a physician' s personal and professional characteristics constitute only one, and not necessarily the most important, determining factor of clinical performance. our study assessed how physician, organizational and systemic factors affect family physicians' performance. Method: our study examined 532 family practitioners who were randomly selected for peer assessment by the College of Physicians and surgeons of ontario. a series of multivariate regression analyses examined the impact of physician factors (e.g., demographics, certification) on performance scores in five clinical areas: acute care, chronic conditions, continuity of care and referrals, well care and records. a second series of regressions examined the simultaneous effects of physician, organizational (e.g., practice volume, hours worked, solo practice) and systemic factors (e.g., northern practice location, community size, physician-to-population ratio). Results: our study had three key findings: (a) physician factors significantly influence performance but do not appear to be nearly as important as previously thought; (b) organizational and systemic factors have significant effects on performance after the effects of physician factors are controlled; and (c) physician, organizational and systemic factors have varying effects across different dimensions of clinical performance. Conclusions: We discuss the implications of our results for performance improvement and physician governance insofar as both need to consider the broader environmental context of medical practice.

Doctor scores on qualifying examinations are significant predictors of quality-of-care problems based on regulatory, practice-based peer assessment.

The accuracy of standardized patient clinical problem presentation was evaluated by videotape rating of a random sample of 839 student-patient encounters, representing 88 patients, 27 cases and two university test sites. Patient-student encounters were sampled from a collaborative inter-university final-year clinical examination of fourth-year medical students which was conducted at the University of Manitoba and Southern Illinois University in 1987 and 1988. The accuracy, replicability and portability of standardized patient cases were evaluated. The average accuracy of patient presentation was 90.2% in 1987 and 93.4% in 1988. Perfect accuracy scores were obtained by 15 patients; however, 11 patients had average scores below 80% with the accuracy of presentation in some encounters being as low as 30%. There were significant differences in the accuracy score achieved by patients trained together for the same case in 6 of 35 possible comparisons. There was also a systematic trend for patients trained at Southern Illinois to be more accurate in their presentation than patients trained at the University of Manitoba. These differences were significant in 5 of the 15 cases used in the examination.