Refocusing on history-taking skills during internal medicine training

A clinical medicine level test at Jinan University School of Medicine reveals the importance of training medical students in clinical history-taking

Backgrounds

Training in the basic interview skills of clinical history-taking has always been a significant component of medical education.

Purpose

This study was designed to identify the factors influence medical students’ history-taking skills learning and develop a way to improve these skills.

Methods

We firstly analysed the academic performance of medical students at Jinan University School of Medicine in different disciplines of the Clinical Medicine Level Test (CMLT), to ensure the students have obtained comprehensive medical education prior to beginning their clinical internships. Next, we conducted a survey among the CMLT participants to seek the underlying causes and corresponding measures to improve history-taking in the future. Before these medical students entered their fifth-year clinical practice, we finally provide them with pre-internship training, including the history-taking workshops with standard patients (SP).

Results

The analysis of the clinical skill sections of the CMLT revealed that the students performed significantly better on clinical operations from multiple disciplines than on medical history-taking. Principal component analysis of the survey questionnaire indicated that the capability of history-taking, course assessments, and awareness of the value of medical history-taking emerged as the key factors forming a cohesive clue for sustaining history-taking implementation. The intervention workshops of employing SP had a positive impact, as evidenced by the students’ feedback and suggestions for improving their ability of history-taking.

Conclusions

This study suggests that strengthening of medical history-taking training is indispensable for training qualified medical students. Workshops with SP is a successful teaching strategy for practicing history-taking, allowing students to spot minute errors and training communication skills.

Multi-source evaluation of an educational program aimed at medical students for interviewing/taking the clinical history using standardized patients

Introduction: Simulations with standardized patients (SP) have long been used for teaching/assessing communication skills. The present study describes and evaluates an experiential training methodology aimed at medical students and based on interviews with standardized simulated patients. The training was focused on developing basic communication skills and taking medical histories. Methods: Longitudinal observational study of a cohort of third-year medical students. Three interviews with SP were carried out and videotaped. These interviews were assessed by the students, the SPs and the professors of the relevant subject areas. Results: 83 students conducted the interviews. The self-evaluations performed by the students showed an improvement between the first and third interviews, as demonstrated by the increase of 6.7% (CI 95%=3.6-10.0%) (p<0.001) in the percentage of detected items. The SPs stated an improvement of 8.5% (CI 95%=2.9-14.1) (p=0.003) from the first to the third interview regarding the percentage of students that showed a level of interest in, and ease with, the patients' concerns. Finally, the teachers found a mean percentage of items identified in the third written clinical history of 61.4% (CI 95%=59.1-63.7) of the total available. Conclusions: This educational program, carried out with standardized simulated patients, showed positive signs of improvement from the first to the third interview, in both the student self-evaluations and the level of interest and ease perceived by the SPs. Additionally, the mean level of information recorded in the written medical histories was considered to be acceptable.

Competencies for first year residents - physicians' views from medical schools with different undergraduate curricula

BACKGROUND

Frameworks like the CanMEDS model depicting professional roles and specific professional activities provide guidelines for postgraduate education. When medical graduates start their residency, they should possess certain competencies related to communication, management and professionalism while other competencies will be refined during postgraduate training. Our study aimed to evaluate the relevance of different competencies for a first year resident required for entrustment decision from the perspective of physicians from medical faculties with different undergraduate medical curricula.

METHODS

Nine hundred fifty-two surgeons and internists from three medical schools with different undergraduate medical curricula were invited to rank 25 competencies according to their relevance for first year residents. The rankings were compared between universities, specialties, physicians' positions, and gender.

RESULTS

Two hundred two physicians participated, 76 from Hamburg University, 44 from Oldenburg University, and 82 from Technical University Munich. No significant differences were found regarding the top 10 competencies relevant for first year residents between the universities. 'Responsibility' was the competency with the highest rank overall. Internists ranked 'Structure, work planning and priorities' higher while surgeons ranked 'Verbal communication with colleagues and supervisors' higher. Consultants evaluated 'Active listening to patients' more important than department directors and residents. Female physicians ranked 'Verbal communication with colleagues and supervisors' and 'Structure, work planning and priorities' significantly higher while male physicians ranked 'Scientifically and empirically grounded method of working' significantly higher.

CONCLUSIONS

Physicians from universities with different undergraduate curricula principally agreed on the competencies relevant for first year residents. Some differences between physicians from different positions, specialties, and gender were found. These differences should be taken into account when planning competence-based postgraduate education training programs.

Details acquired from medical history and patients' experience of empathy--two sides of the same coin

BACKGROUND

History taking and empathetic communication are two important aspects in successful physician-patient interaction. Gathering important information from the patient's medical history is needed for effective clinical decision making while empathy is relevant for patient satisfaction. We wanted to investigate whether medical students near graduation are able to combine both skills as required in daily medical practice.

METHODS

Thirty near graduates from Hamburg Medical School participated in an assessment for clinical competences including a consultation hour with five standardized patients. Each patient interview was videotaped and standardized patients rated participants with the CARE questionnaire for consultation and relational empathy. All videotaped interviews were rated with a checklist based on the number of important medical aspects for each case. Data were analysed with the linear mixed model to correct for random effects. Regression analysis was performed to look for correlations between the number of questions asked by a participant and their respective empathy rating.

RESULTS

Of the 123 aspects that could have been gathered in total, students only requested 56.4% (95% CI 53.5-59.3). While no difference between male and female participants was found, a significant difference (p<.001) was observed between the two parts of the checklist with 61.1% (95% CI 57.9-64.3) of aspects asked for in part 1 (patient's symptoms) versus 52.0 (95 47.4-56.7) in part 2 (further history). All female standardized patients combined rated female participants (mean score 14.2, 95% CI 12.3-16.3) to be significantly (p<.01) more empathetic than male participants (mean score 19.2, 95% CI 16.3-22.6). Regression analysis revealed no correlation between the number of medical aspects gathered by a participant and his or her respective empathy score given by the standardized patient in the CARE questionnaire.

CONCLUSION

Gathering sufficient medical data from a patient's history and empathetic communication are two completely separate sides of the coin of history taking. While both skills have to be acquired during medical school training with particular focus on their respective learning objectives, medical students need to be provided with additional learning and feedback opportunities where they can be observed exercising both skills combined as required in physicians' daily practice.

Exploring the benefits of user education: a review of three case studies

This paper builds on Leslie Morton's vision of enabling users through education and training. It describes three different approaches to mediated training for medical students and clinicians provided by peers, juniors (i.e. medical students) and information specialists (i.e. clinical librarians) and considers the benefits to the participants. The training was provided either on a one-to-one basis or within teams in their work environments (e.g. offices, wards, team meetings). The first two projects (peer tutoring and reverse mentoring) suggest that contextualized training, using intermediaries, provides the direct benefit of cost-effective IT skill development and the indirect benefits deriving from the interactions between the trainers and the target groups. The third project, the outreach librarian study, provides evidence of both direct benefits (i.e. time saved, quality of service, skills acquired, financial savings and improved evidence-based medicine implementation) and indirect, long-term benefits relating to more social issues (e.g. perceptions of the library, clinical teams, job satisfaction and patient interactions). The general conclusion to emerge from this review of case studies is that the concept of educational benefits is very broad and that empirical studies need to look at both obvious and less obvious benefits.

Occupational medical history taking: how are today's physicians doing? A cross-sectional investigation of the frequency of occupational history taking by physicians in a major US teaching center

Occupational illness plays a prominent role in the health of society, yet physicians frequently neglect occupational history-taking both in clinical practice and in medical education. This study sought to examine the trends as well as related factors that influence the taking of occupationally related histories. A total of 2050 charts were reviewed for occupational information as well as several patient demographics. Physicians obtained gender and age histories in approximately 99% of their patients; however; they only completed an occupational history in 27.8%. Characteristics such as smoking, male gender, family cancer history, middle age, and medical (vs. surgical) admission were all correlated with obtaining an occupational history. Physicians continue to do a poor job of occupational history-taking and medical education must correct the situation.

Reinforcement of occupational history taking: a success story

BACKGROUND

This article describes the results of a retrospective study of 3 classes of medical students who participated in a targeted occupational and environmental health curriculum at the University of Connecticut School of Medicine.

PURPOSE

We wanted to determine if targeted focused curricular interventions which integrated occupational and environmental health principles into routine history taking would result in increased scores on the number of questions posed during the Clinical Skills Assessment Program in the 4th year.

METHODS

We analyzed Clinical Skills Assessment Program questions for 3 graduating medical school classes from 1997 to 1999.

RESULTS

It appears that intense, focused training may increase the occupational and environmental questions which students ask. By revisiting the components of the history during the 3rd year, the final assessment of 4th-year students substantially and significantly increased.

CONCLUSIONS

Those who wish to stem the decline in history-taking skills as students enter their clinical years should consider reinforcing these skills using structured programs and practice in areas of the history that are traditionally neglected but recognized as essential in gathering comprehensive data on patients.

Physicians' recognition of the symptoms experienced by HIV patients: how reliable?

To assess how well physicians recognize common symptoms in HIV patients and identify factors associated with symptom recognition, a multicenter cross-sectional survey was performed in a random sample of 118 hospitalized and 172 ambulatory HIV patients, and their attending physicians. Patients' reports of 16 different symptoms were compared to physicians' reports of whether each symptom was present and/or specific treatments prescribed. Overall, fatigue, anxiety, skin problems, fever, and weight loss were more often recognized by physicians than other symptoms. Agreement between patients and physicians was poor to moderate, with Kappa statistics ranging from 0.17 (dry mouth) to 0.58 (fever). Recognition was independently more likely for ambulatory patients (adjusted odds ratio 1.69, P < 0.001) and for patients seen as sicker (adjusted odds ratio 1.88, P < 0.001). Appropriate symptom management requires improved symptom recognition. More systematic clinical examinations, including attentive patient interview, are needed.

Occupational history collection by third-year medical students during internal medicine and surgery inpatient clerkships

Occupational history is fundamental for the evaluation of possible workplace influences on health. We reviewed 2,922 initial history-and-physical reports from 137 third-year medical students to examine occupational history collection. Overall reporting frequencies were recorded as the following: industry, 55.8%; occupation, 70.0%; specific occupational exposure, 8.4%; smoking status, 91.4%. Patients younger than 40 years of age and women were significantly less likely than other older patients and men to have notations of occupation and industry. Surgery students were less likely than internal medicine students to collect data for industry (41.6% vs 66.6%, P < 0.001), occupation (57.4% vs 79.7%, P < 0.001), and smoking (88.1% vs 94.0%, P < 0.001). The highest frequencies of notation were those for circulatory and respiratory conditions. No significant differences were noted for student gender, academic quarter, or week of clerkship. Clinical occupational medicine teaching should emphasize the need to collect occupational information from all patients, including women and young persons.

Deciphering the physician-older patient interaction

OBJECTIVE

The purpose of this article is to provide a commentary on non-verbal communication in the physician-older patient interaction.

METHOD

A literature review of physician-older patient communication yielded several published studies on this topic. Nonverbal behaviors were rarely examined in this body of literature even though the need to adopt a more "biopsychosocial" model of care was mentioned in several of the articles. The nonverbal communication literature was also reviewed to determine whether aging had been a variable of interest with regard to encoding (sending) and decoding communication (receiving) skills.

RESULTS

To date there have been very few studies that have investigated the role of nonverbal communication in the physician-older patient interaction. Selected encoding and decoding characteristics for both physicians and patients are discussed with the context of the aging process. In lieu of direct evidence linking nonverbal behavior and physician-older patient communication, possible implications are offered for the following characteristics: expression of emotion, pain expression, gestures, gaze, touch, hearing, and vocal affect. Three relevant outcomes (satisfaction with care, quality of life, and health status) are also discussed within the nonverbal behavior-aging framework.

CONCLUSION

The connection between nonverbal behavior and how physicians and older patients interact with one another has not been rigorously examined. Identifying and improving nonverbal communication will likely enhance the verbal exchange in the medical encounter and may improve the older patient's quality of care.