Medical Examiner


Hate exams (medical or otherwise)? What if a computer designed them just for you?

The paper-and-pencil standardized test, that mainstay of meritocracy, soon will join the manual typewriter, vinyl records, and communism on the scrap heap of the 20th century. Computerized exams are rapidly replacing it. This October, business school applicants become the latest to put down their No. 2 pencils and take the Graduate Management Admissions Test on-screen.

The technology behind the new tests is remarkable. Using a simple form of artificial intelligence, the computer selects questions tailored to the test-taker, shortens the test, and displays results instantly. These changes make some people nervous, but they are nothing compared to the technology’s uses in medical care. Researchers are employing the same advances in artificial intelligence to create a computer program that interviews patients. And, believe it or not, it could make your care better.

In 1994, nurses became the first to switch from paper to computer for their national licensing exams. Since then, architects, pharmacists, stockbrokers, and even electrologists (the hair-removal people) have made the leap. Aspiring graduate students can already opt to take the Graduate Record Examination on computer, and the paper GRE will be eliminated in 1999. Physician exams will likely go micro next year. The SAT, required for admission by most colleges, will convert in 2003, at least in urban areas.

Test makers are switching for several reasons–printing costs are lower for computerized tests, the technology is there–but especially because of complaints about the length of the old tests. The paper GRE and GMAT took five hours; nursing exams, two days. They had to be that long, though, because a paper test is dumb. It can’t select which questions to ask. In order to identify your exact level of, say, math ability, it must ask dozens of questions that range from ridiculously easy to sort-of-easy to impossibly hard. Twenty math questions might suffice to rank you in the top or bottom half of your cohort, but admissions committees want to know whether you’re in the 43rd, 50th, or 89th percentile.

T he breakthrough came when test designers (or “psychometricians,” as they like to call themselves) programmed computers to select questions based on your previous answers, just as in “.” When you get a question right, the computer asks a harder one, and an easier one when you get one wrong. If you’re at the 63rd percentile, you’ll get all the easy ones and miss all the hard ones, so the computer skips most of both groups and sticks to middle-level questions. That saves time (the new nursing exam takes less than two hours, on average) and also makes tests more accurate, since the computer can ask more questions around your level to ensure you really are in the 63rd percentile.

Many people fear the new tests. Enrollment for the final paper GMAT, given this past June, jumped 25 percent. Others claim the tests are unfair. (For some typical complaints, click.) The change in standardized testing is just a mouse step, however, compared with what intelligent question-asking programs will soon do for medicine. Using the same technology, researchers are now developing programs to interview patients and measure, sometimes better than doctors can, how well treatments are working.

For some diseases, such as diabetes or high cholesterol, blood tests and other tools help doctors evaluate and fine-tune treatment. However, many other diseases–arthritis, urinary trouble, depression–have no such tests, so doctors had to rely on personal experience to evaluate treatments. Then a new school of “outcomes researchers” suggested an answer: Regardless of your disease, they argued, effective treatment should improve your quality of life. So why not devise a standardized test to measure the quality of patients’ lives?

A few years ago, outcomes-research guru John Ware designed such a test, the SF-36. The test asks things like “Does your health limit you in walking a block? Several blocks? More than a mile?” (If you’re curious about your own SF-36 score, click here.) Questions cover pain, mood, physical function, and the like. Doctors can give patients the test before and after treatment for almost any disease. It’s no substitute for a doctor’s evaluation, but it can show how you’re doing in relation to your own previous condition and to others similarly treated. Research shows, for example, that patients’ SF-36 scores consistently improve after hip-replacement surgery (for severe arthritis) and prostate surgery (for trouble urinating) when they’re done right.

N ot all treatments are as dramatic as hip replacement, however. Medicine often produces subtler results that may be difficult for a five-minute test like the SF-36 to capture. A change in arthritis medication may enable a patient to button his shirt, or to play singles tennis as opposed to doubles. To pick up these changes, a paper test would have to ask more detailed questions, and soon would become impractically long. The GRE and GMAT designers showed, however, that computer-tailored tests might help. So, if a patient answers that he has trouble getting out of bed, a computer could skip questions about vigorous activity and focus on questions about ordinary daily activities.

With funding from Kaiser Permanente, the HMO giant, Ware is designing just such a test, a kind of standardized computer/patient interview. He expects that, in five years, 5 percent to 10 percent of all patients will take the test during doctor visits. He even envisions giving it at home via Internet TV and, if patients want, having the computer alert their doctors if the test finds their condition worsening.

Ware’s group has developed the mental-health segment first. It asks questions like: “Have you wanted to harm yourself? How often do you feel downhearted and blue? Have you had a lot of energy?” These alone could have valuable uses. In preliminary studies, for example, the questions can show if Prozac is working or not. And the computer test may be better than doctors at recognizing problems in mentally healthy patients. For instance, the test can catch when drugs cause slight fatigue or make it harder to enjoy life fully, as some heart medications can. Doctors often miss these effects. The test may make them think twice about medicines that take the fun out of patients’ lives.

In the future, computers might even make up test questions and conduct personalized interviews of job applicants, college applicants, and even patients. Will that be good? Well, any technology can be used for good or ill. If doctors start using computer interviews as an excuse to talk to patients less, medical care will deteriorate. Patients could certainly get annoyed by having to take even a five-minute computer test every time they see a doctor. But artificial intelligence has enormous potential to make care better. The question is, do we trust Kaiser to use it that way?

Does computerization give ETS an unfair advantage? If you missed our link earlier, click.