History-taking Skills Research Articles

Perceptions of postgraduate trainees on the impact of objective structured clinical examinations on their study behavior and clinical practice.

BackgroundThe objective structured clinical examination (OSCE) is a commonly used method of assessing clinical competence at various levels, including at the postgraduate level. How the OSCE impacts on learning in higher education is poorly described. In this study, we evaluated the perceptions of postgraduate trainees regarding the impact of the OSCE on their study and clinical behavior.MethodsWe employed an explorative qualitative research design by conducting focus group discussions with 41 pediatric postgraduate trainees at the College of Health Science, Makerere University. A semi-structured tool was used to obtain the views and experiences of the trainees. Transcripts from the discussion were analyzed in an iterative manner using thematic content analysis.ResultsThe trainees reported the OSCEs as a fair and appropriate tool for assessing clinical competency at the postgraduate level. However, they noted that whereas OSCEs assess a broad range of skills and competencies relevant to their training, there were areas that they did not adequately assess. In particular, OSCEs did not adequately assess in-depth clinical knowledge or detailed history-taking skills. Overall, the majority of the trainees reported that the OSCEs inspired them to study widely and improve their procedural and communication skills.ConclusionOSCEs are a useful tool for assessing clinical competencies in postgraduate education. However, the perceived limitations in their ability to assess complex skills raises concerns about their use as a standalone mode of assessment at the postgraduate level. Future studies should evaluate how use of OSCEs in combination with other assessment tools impacts on learning.

Recording medical students' encounters with standardized patients using Google Glass: providing end-of-life clinical education.

Medical education today frequently includes standardized patient (SP) encounters to teach history-taking, physical exam, and communication skills. However, traditional wall-mounted cameras, used to record video for faculty and student feedback and evaluation, provide a limited view of key nonverbal communication behaviors during clinical encounters. In 2013, 30 second-year medical students participated in an end-of-life module that included SP encounters in which the SPs used Google Glass to record their first-person perspective. Students reviewed the Google Glass video and traditional videos and then completed a postencounter, self-evaluation survey and a follow-up survey about the experience. Google Glass was used successfully to record 30 student/SP encounters. One temporary Google Glass hardware failure was observed. Of the 30 students, 7 (23%) reported a "positive, nondistracting experience"; 11 (37%) a "positive, initially distracting experience"; 5 (17%) a "neutral experience"; and 3 (10%) a "negative experience." Four students (13%) opted to withhold judgment until they reviewed the videos but reported Google Glass as "distracting." According to follow-up survey responses, 16 students (of 23; 70%) found Google Glass "worth including in the [clinical skills program]," whereas 7 (30%) did not. Google Glass can be used to video record students during SP encounters and provides a novel perspective for the analysis and evaluation of their interpersonal communication skills and nonverbal behaviors. Next steps include a larger, more rigorous comparison of Google Glass versus traditional videos and expanded use of this technology in other aspects of the clinical skills training program.

Board #224 - Program Innovation Integration of Simulation Training throughout Undergraduate Medical Education (Submission #10053)

Objectives For more than 20 years, medical literature has increasingly documented the need for students to learn, practice, and demonstrate competence in basic clinical knowledge, assessment skills, and procedural skills. In 2001, the LSUHSC School of Medicine New Orleans replaced its traditional Introduction to the Clinical Medicine (ICM) course with the Science and Practice of Medicine (SPM) course. Curriculum innovations included changes to the lecture format, reduction in lecture hours, changes to the lab structure, additional small group instruction, and the incorporation of computer-based learning. One of the key adaptations to the new curriculum was the addition of simulation (role play, anatomical models, low-high fidelity simulators) in the Clinical Skills Lab and Human Patient Simulation Lab (HPS). Description The Clinical Skills Lab (CSL) is designed as an active learning approach that focuses on small group instruction, hands-on training, peer-to-peer observation, and immediate feedback in a non-stressful controlled environment. Procedural skill instruction at the level of first and second-year medical students permits reinforcement of basic science principles in clinical case scenarios. The CSL allows the preclinical students to learn, practice, and demonstrate competence in 40 basic skills over the 15 sessions. Third year students participate in the HPS Lab, and are required to manage patients that relate to their clerkship curriculum. Over the course of the year, students manage and treat eight simulated patients with a variety of illnesses which are listed below. In 2011, LSUHSC extended the use of simulation into the fourth year with a new course called Critical Concepts. This course was developed to ensure that students can recognize and manage core conditions that clinical departments believed necessary for all interns. This course currently has eight participating departments: Emergency Medicine, Pulmonary Critical Care, Pediatrics/NICU, Anesthesia, Obstetrics/Gynecology, Orthopedics, Psychiatry and Surgery. The table below shows the department and areas of instruction.Conclusion The SPM course allows freshman medical students the opportunity to supplement their history-taking skills with rudimentary physical assessment and procedure/skill acquisition. Second-year medical students are encouraged to solve more complex medical cases involving lab and physical exam abnormalities that require integration of previously acquired CSL skills. The Critical Concept course prepares students to enter residency with a more sophisticated understanding of the complexity of diseases and patient management. While all of these courses use various types of simulation training, they are not designed to replace real clinical patient experiences. They are designed to provide early exposure to clinical medicine, challenge students to apply their medial knowledge, enhance patient management skills, and provide the opportunity to practice skills/procedures in a patient-free environment. Disclosures None

Content and timing of feedback and reflection: a multi-center qualitative study of experienced bedside teachers.

BackgroundCompetency-based medical education increasingly recognizes the importance of observation, feedback, and reflection for trainee development. Although bedside rounds provide opportunities for authentic workplace-based implementation of feedback and team-based reflection strategies, this relationship has not been well described. The authors sought to understand the content and timing of feedback and team-based reflection provided by bedside teachers in the context of patient-centered bedside rounds.MethodsThe authors conducted a thematic analysis qualitative study using transcripts from audio-recorded, semi-structured telephone interviews with internal medicine attending physicians (n= 34) identified as respected bedside teachers from 10 academic US institutions (2010–2011).ResultsHalf of the respondents (50%) were associate/full professors, with an average of 14 years of academic experience. In the context of bedside encounters, bedside teachers reported providing feedback on history-taking, physical-examination, and case-presentation skills, patient-centered communication, clinical decision-making, leadership, teaching skills, and professionalism. Positive feedback about physical-exam skills or clinical decision-making occurred during encounters, positive or constructive team-based feedback occurred immediately following encounters, and individualized constructive feedback occurred in one-on-one settings following rounding sessions. Compared to less frequent, emotionally-charged events, bedside teachers initiated team-based reflection on commonplace “teachable moments” related to patient characteristics or emotions, trainee actions and emotions, and attending physician role modeling.ConclusionsBedside teachers use bedside rounds as a workplace-based method to provide assessment, feedback, and reflection, which are aligned with the goals of competency-based medical education. Embedded in patient-centered activities, clinical teachers should be encouraged to incorporate these content- and timing-related feedback and reflection strategies into their bedside teaching.

How we developed a locally focused Global Health Clinical Preceptorship at Weill Cornell Medical College

Background: Global health educational programs within U.S. medical schools have the opportunity to link their “global” focus with local circumstances by examining the challenges underserved communities face in the United States.Aim: Students in Weill Cornell Medical College’s Global Health Clinical Preceptorship (GHCP) learn history-taking and physical examination skills while gaining exposure to local health care disparities and building cultural competency.Methods: First-year medical students in the program are placed in the office of a physician who works with underserved patient populations in New York City. Students receive an orientation session, shadow their preceptors one afternoon per week for seven weeks, complete weekly readings and assignments on topics specific to underserved populations, attend a reflection session, and write a reflection paper.Results: In three years, 36% of first-year students (112 of 311) opted into the elective GHCP program. Students reported gaining a better understanding of the needs of underserved patient populations, being exposed to new languages and issues of cultural competency, and having the opportunity to work with role model clinicians.Conclusions: The GHCP is a successful example of how global health programs within medical schools can incorporate a domestic learning component into their curricula.

General Practitioners' Procedures for Sexual History Taking and Treating Sexual Dysfunction in Primary Care

Good history-taking skills are the first step towards achieving a correct diagnosis of sexual dysfunction (SD). However, studies show most general practitioners (GPs) do not take the initiative to ask the patient about SD, and when diagnosing a condition, they tend to give preference to their own criteria over clinical guidelines. The aim of this study is to characterize GPs' attitudes towards taking sexual history, identifying its frequency and focus, and to describe GPs' diagnostics and therapeutic approaches including the use of clinical guidelines, exploring patients' and doctor-related differences. Cross-sectional study using confidential self-administrated questionnaires applied to GPs working in primary healthcare units in the Lisbon region. Data concerning GPs' consultation of guidelines, active exploration of SD in male and in female patients, and focus on sexual history taking was collected. Of the 50 participants (73.5% response rate), 15.5% actively ask their patients about SD. The main reasons for asking patients about their sexuality are diabetes (84.0%), prescription of medication with adverse effects on sexuality (78.0%), and family planning (72.0%), the latter being a significantly more frequent reason for GPs with 20 or less years of practice. Routine sexual history taking (22.0%) appears as one of the least mentioned motives. The percentage of appointments with active exploration of SD was positively associated with guidelines' consultation, as well as considering the specialty as a good source of information and having longer appointments when SD is mentioned. However, 76.0% report not having consulted any guidelines in the previous year. Lack of time (31.6%) and low accessibility (25.0%) were referred to as the main reasons for not consulting guidelines. Routine sexual history taking and consultation of guidelines about SD are not yet a generalized practice in primary care. Data should be interpreted with caution as they are self-reported. Further objective measurement such as direct observation or clinical files consultation should be implemented.

Assessing Student Pharmacists’ Ability to Identify Drug-Related Problems in Patients Within a Patient-Centered Medical Home

To quantify, describe, and categorize patient drug-related problems (DRPs) and recommendations identified by fourth-year (P4) student pharmacists during a live medication reconciliation activity within a patient-centered medical home (PCMH). Fourth-year student pharmacists conducted chart reviews, identified and documented DRPs, obtained live medication histories, and immediately provided findings and recommendations to the attending physicians. Documentation of DRPs and recommendations were analyzed retrospectively. Thirty-eight students completed 99 medication reconciliation sessions from June 2011 to October 2012 during their advanced pharmacy practice experience (APPE). The students obtained 676 patient medication histories and identified or intervened on 1308 DRPs. The most common DRPs reported were incomplete medication list and diagnostic/laboratory testing needed. Physicians accepted 1,018 (approximately 78%) recommendations. Student pharmacists successfully identified and reduced DRPs through a live medication reconciliation process within an academic-based PCMH model. Their medication history-taking skills improved and medication use was optimized.

Perception of Undergraduate Pediatric Surgery Clerkship in a Developing Country

Medical students' perception of their clerkship may influence their choice of ultimate career. In most medical schools, pediatric surgery clerkship (PSC) is not compulsory. This study evaluates the perception of PSC by students and determines the importance of this on the choice of pediatric surgery as a career. We surveyed 2009 and 2010 graduating medical classes of University of Nigeria, Nsukka, using self-administered questionnaires. The clerkship evaluation was assessed using a 3-point scale (1 = poor and 3 = excellent). Students who had PSC were analyzed to compare their rating of pediatric surgery vis-à-vis other clinical clerkships and determine the effect of the clerkship on their ultimate choice of a career. Overall response rate was 70.3% (275/391), and 119 (43.3%) had PSC. For overall quality, PSC rated (2.16) compared with general surgery (2.04), internal medicine (2.11), obstetrics and gynecology (2.13), and pediatrics (2.37). Aspects of PSC that rated poorly include opportunity to participate in direct patient care, feedback on performance during clerkship, ability to manage problem in a general medical setting, and experience in learning history-taking skills and interpretation of laboratory data. Among the students who had PSC, 14 (11.8%) selected pediatric surgery as a specialty choice compared with 13 (8.3%) who did not have PSC (p = 0.457). Of those that had PSC, pediatric surgery was selected as a career by 2 of 19 (10.5%), 6 of 63 (9.5%), and 6 of 37 (16.2%) who rated PSC as poor, just right, and excellent, respectively. The decision to select pediatric surgery was influenced mostly by clerkship experience in 37% (10/27) and personal satisfaction in 40.7% (11/27). Improvement in the quality of PSC may involve more participation of the students in direct patient care (n = 54; 45.4%) and enhancement in student-faculty interaction (n = 31; 26.1%). PSC may have a good rating in our setting. Nonetheless, improving the quality and experience of the clerkship through a well-thought-out curriculum modification may enhance interest in pediatric surgery as a career choice.

Training the Psychiatrist of the Future

Training the Psychiatrist of the Future

Assessing Competence of Orthopaedic Residents: The Reliability and Validity of an Objective Structured Clinical Examination After a Sports Medicine Rotation

The traditional method of orthopaedic training in Canada utilizes a time-based system, combined with a formal exit examination. Increasing interest in competency-based curriculum has raised the issue of how to test in-training competence. Currently, the most commonly used method is the In-Training Evaluation Report (ITER), which is known to be relatively subjective in nature; the true establishment of competence would likely benefit from the addition of an objective assessment1,2. The definition of competence varies, but relates to an individual’s ability to perform in the workplace to the required standard3. In surgery, competence is required in many areas, including surgical skill and clinical decision-making. Currently, orthopaedics is lacking a reproducible, objective measurement of resident competence. Objective Structured Clinical Examinations (OSCEs) are an important aspect of certifying examinations in many countries. First developed in the late 1970s, an OSCE consists of multiple, timed stations at which each candidate is faced with a discrete patient or case-based clinical task and is evaluated in an objective and structured way; both the task and the assessment are standardized4-6. An OSCE is especially suited to testing aspects of the role of medical expert4,7,8. To our knowledge, there is very little published literature on the validity and reliability of OSCEs in orthopaedics. Recently, Beran et al. used an OSCE to assess history-taking and physical examination skills of orthopaedic residents, which served to highlight deficiencies in resident knowledge9. The ability to formulate valid and reliable in-training OSCEs may become an essential tool in competency-based orthopaedic training and may be used to assess resident competence regularly throughout training, to identify residents with knowledge deficits compared with their peers, and to allow appropriate remediation. A compulsory module at our university is a …

History-taking and clinical examination skills from a stoma nurse's perspective

Comprehensive history-taking and clinical examination skills are examples of role development for a stoma care nurse specialist. Comprehensive history-taking is a thorough exploration of a patient's presenting complaint and the gathering of subjective information, while clinical examination is the gathering of objective information from a head-to-toe assessment or a focused assessment of a particular body system. This paper demonstrates the application of comprehensive history-taking and gastrointestinal clinical examination skills by the stoma care nurse in a clinical community setting, and explores their advantages and disadvantages in stoma care practice.

G09 Do Parents Agree with Examiners When Rating Student Competence in Exams?

AimsTo compare examiner and parental ratings of students undertaking a summative clinical assessment of history-taking and examination skills in a ward based setting.MethodsParents of patients participating in the 4th year...

An Educational Tool for Teaching Medication History Taking to Pharmacy Students

To implement and evaluate the use of a situated-learning experience to prepare second-year pharmacy students to conduct medication history interviews in preparation for introductory pharmacy practice experiences (IPPE) at ambulatory clinic sites. Second-year doctor of pharmacy (PharmD) students (n=200) used the Medication Mysteries Infinite Case Tool, a game-like educational tool in which groups of 3 students assumed the roles of pharmacist, patient, and observer and rolled a die and drew cards to determine the drugs, patient personality, medication problems, and other variables that guided a medication history taking session. After the laboratory session, faculty members assessed students' medication history-taking skills. One hundred sixteen (58%) and 78 (39%) of 200 students achieved excellence or competence, respectively, on the final assessment. Two weeks after the assessment, 53 of 200 (26.5%) students completed a survey instrument. The respondents indicated that their self-confidence in conducting medical history taking significantly improved following completion of the learning experience. Using the Medication Mysteries Infinite Case Tool increased students' confidence and skills in conducting medication history taking prior to their clinical IPPE experience.

Are students ready for meaningful use?

BackgroundThe meaningful use (MU) of electronic medical records (EMRs) is being implemented in three stages. Key objectives of stage one include electronic analysis of data entered into structured fields, using decision-support tools (e.g., checking drug–drug interactions [DDI]) and electronic information exchange.ObjectiveThe authors assessed the performance of medical students on 10 stage-one MU tasks and measured the correlation between students’ MU performance and subsequent end-of-clerkship professionalism assessments and their grades on an end-of-year objective structured clinical examination.ParticipantsTwo-hundred and twenty-two third-year medical students on the internal medicine (IM) clerkship.Design/main measuresFrom July 2010 to February 2012, all students viewed 15 online tutorials covering MU competencies. The authors measured student MU documentation and performance in the chart of a virtual patient using a fully functional training EMR. Specific MU measurements included, adding: a new problem, a new medication, an advanced directive, smoking status, the results of screening tests; and performing a DDI (in which a major interaction was probable), and communicating a plan for this interaction.Key resultsA total of 130 MU errors were identified. Sixty-eight (30.6%) students had at least one error, and 30 (13.5%) had more than one (range 2–6). Of the 130 errors, 90 (69.2%) were errors in structured data entry. Errors occurred in medication dosing and instructions (18%), DDI identification (12%), documenting smoking status (15%), and colonoscopy results (23%). Students with MU errors demonstrated poorer performance on end-of-clerkship professionalism assessments (r =−0.112, p=0.048) and lower observed structured clinical examination (OSCE) history-taking skills (r =−0.165, p=0.008) and communication scores (r= − 0.173, p=0.006).ConclusionsMU errors among medical students are common and correlate with subsequent poor performance in multiple educational domains. These results indicate that without assessment and feedback, a substantial minority of students may not be ready to progress to more advanced MU tasks.

Exploring graphic pathographies in the medical humanities

While diagrams and visual aids are often used to help patients understand and remember information, the teaching of visual literacy skills in medical education curricula is still in its infancy....

Do communication training programs improve students’ communication skills? - a follow-up study

BackgroundAlthough it is taken for granted that history-taking and communication skills are learnable, this learning process should be confirmed by rigorous studies, such as randomized pre- and post-comparisons. The purpose of this paper is to analyse whether a communication course measurably improves the communicative competence of third-year medical students at a German medical school and whether technical or emotional aspects of communication changed differently.MethodA sample of 32 randomly selected students performed an interview with a simulated patient before the communication course (pre-intervention) and a second interview after the course (post-intervention), using the Calgary-Cambridge Observation Guide (CCOG) to assess history taking ability.ResultsOn average, the students improved in all of the 28 items of the CCOG. The 6 more technically-orientated communication items improved on average from 3.4 for the first interview to 2.6 in the second interview (p < 0.0001), the 6 emotional items from 2.7 to 2.3 (p = 0.023). The overall score for women improved from 3.2 to 2.5 (p = 0.0019); male students improved from 3.0 to 2.7 (n.s.). The mean interview time significantly increased from the first to the second interview, but the increase in the interview duration and the change of the overall score for the students’ communication skills were not correlated (Pearson’s r = 0.03; n.s.).ConclusionsOur communication course measurably improved communication skills, especially for female students. These improvements did not depend predominantly on an extension of the interview time. Obviously, “technical” aspects of communication can be taught better than “emotional” communication skills.

Are nurse and pharmacist independent prescribers making clinically appropriate prescribing decisions? An analysis of consultations

Legislation and health policy enabling nurses and pharmacists to prescribe a comprehensive range of medicines has been in place in the UK since 2006. Our objective was to evaluate the clinical appropriateness of prescribing by these professionals. A modified version of the Medication Appropriateness Index (MAI) was used by 10 medical, seven pharmacist and three nurse independent raters to evaluate a sample of 100 audio-recorded consultations in which a medicine was prescribed by a nurse or pharmacist. Raters were current prescribers with recognized experience in prescribing. Consultations were recorded in nine clinical practice settings in England. Raters' analysis indicated that, in the majority of instances, nurses and pharmacists were prescribing clinically appropriately on all of the ten MAI criteria (indication, effectiveness, dosage, directions, practicality, drug-drug interaction, drug-disease interaction, duplication, duration, cost). Highest mean 'inappropriate' ratings were given for correct directions (nurses 12%; pharmacists 11%) and the cost of the drug prescribed (nurses 16% pharmacists 22%). Analysis of raters' qualitative comments identified two main themes: positive views on the overall safety and effectiveness of prescribing episodes; and potential for improvement in nurses' and pharmacists' history-taking, assessment and diagnosis skills. Nurses and pharmacists are generally making clinically appropriate prescribing decisions. Decisions about the cost of drugs prescribed and assessment and diagnostic skills are areas for quality improvement.

Useful apps for OSCE practice

OSCE (objective structured clinical examination) time can be a stressful time for many medical students who might feel underprepared and inexperienced. In this article we give an overview of the most useful apps for OSCE practice. -Free (offers in-app purchases, £3.99 to unlock all content) -Android (4.4/5 from 238 reviews) -Apple (4/5 from 22 reviews) They say: “Learn on the go with our comprehensive collection of high quality OSCE guides covering a wide range of commonly tested clinical skills.” Features -Guides to the following OSCEs: cardiovascular, respiratory, gastrointestinal, neurology, musculoskeletal, endocrine, obstetrics & gynaecology, ear, nose & throat, breast examination, clinical procedures and communication skills -Video demonstrations and images -Checklist mark schemes -Customisable timer Student BMJ’s verdict: This is one of the few OSCE apps on the market which includes videos and images of the clinical examinations, as well as text. Most of the content is locked until paid for. -Free - offers in-app purchase of £1.49 -Android (4/5 from 61 reviews) -Not available for Apple devices They say “Revision aide for medical OSCE examinations. Contains 47 mock OSCE sheets, which provides a checklist for students to work through in pairs, checking off each item to ensure correct procedure” Features -47 mock OSCE checklists - Stations include history-taking, practical and clinical skills - Available in test and practical mode - Timer mode - Exam mode which runs consecutive, random stations Student BMJ’s verdict You have to pay for the clinical OSCE checklists, but the free material is good quality. The app is easy to use and well designed. Being able to …

Handwritten undergraduate case reports

This article describes a 'back to the future' approach to case 'write-ups', with medical students producing handwritten instead of word-processed case reports during their clinical placements. Word-processed reports had been found to have a number of drawbacks, including the inappropriate use of 'cutting and pasting', undue length and lack of focus. We developed a template to be completed by hand, based on the hospital 'clerking-in process', and matched this to a new assessment pro forma. An electronic survey was conducted of both students and assessors after the first year of operation to evaluate impact and utility. The new template was well received by both students and assessors. Most students said they preferred handwriting the case reports (55.6%), although a significant proportion (44.4%) preferred the word processor. Many commented that the template enabled them to effectively learn the structure of a case history and to improve their history-taking skills. Most assessors who had previously marked case reports felt the new system represented an improvement. The average time spent marking each report fell from 23.56 to 16.38 minutes using the new pro forma. Free text comments from the survey have led to the development of a more flexible case report template better suited to certain specialties (e.g. dermatology). This is an evolving process and there will be opportunities for further adaptation as electronic medical records become more common in hospital.

Breaking News: Simulation Drives Innovation in Teaching, Learning, and Clinical Practice

Breaking News: Simulation Drives Innovation in Teaching, Learning, and Clinical Practice