history taking case study

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• Published: 30 April 2015

The importance of good history taking: a case report

• Durga Ghosh 1 &
• Premalatha Karunaratne 2  

Journal of Medical Case Reports volume  9 , Article number:  97 ( 2015 ) Cite this article

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Introduction

Early comprehensive geriatric assessment (CGA) with good history-taking is essential in assessing the older adult.

Case presentation

Our patient, a 75-year-old Caucasian woman, was originally admitted to hospital for investigation of iron deficiency anemia. During admission, she developed pneumonia and new intermittent atrial fibrillation in association with a right-sided weakness, which was felt to be new at the time.

Following this episode, she was treated for a further chest infection and, despite clinical improvement, her inflammatory markers failed to settle satisfactorily.

She was transferred to her local hospital for a period of rehabilitation where further neurological findings made the diagnosis of solely stroke questionable; these findings prompted further history-taking, investigations and input from other disciplines, thereby helping to arrive at a working diagnosis of vasculitic neuropathy.

Conclusions

The case aims to highlight the importance of taking a good history and performing an early comprehensive assessment in the older adult.

Good history-taking, an essential part of a comprehensive assessment in an older adult [ 1 ], helped reveal an underlying debilitating neuropathy.

Our patient, a 75-year-old Caucasian woman, was admitted to hospital for investigation of iron deficiency anemia in June 2013. Her hemoglobin (Hb), hematocrit and mean cell volume (MCV) levels preadmission were 10.1g/dL, 0.33 and 77 fL, respectively.

There was little known about her past medical history aside from type 2 diabetes mellitus (T2DM) requiring insulin, hypertension and chronic obstructive pulmonary disease (COPD). Investigation for iron deficiency anemia confirmed extensive diverticular disease with normal upper gastrointestinal (GI) endoscopy and duodenal biopsy.

During the same admission, she developed a hospital-acquired pneumonia and new intermittent atrial fibrillation.

Coinciding with this period, she developed a new dysphasia and what was perceived to be a ‘new’ right-sided weakness. A computed tomography (CT) brain scan showed no acute change and she was treated as a patient with ischemic stroke, given the clinical findings.

She was treated for a further pneumonia in hospital and also underwent investigations such as a CT pulmonary angiography (CTPA) scan, which ruled out pulmonary embolism but confirmed partial left lung collapse; subsequent bronchoscopy was negative for malignancy. Her inflammatory markers remained elevated with her C-reactive protein (CRP) level approximately 140 and white cell count (WCC) 14 but she remained mentally alert and made clinical improvement. Her repeat chest X-rays were also unchanged. Given the clinical improvement, she was deemed suitable for transfer for stroke rehabilitation to her local hospital in August 2013. Her medications on transfer were: Novomix 30 twice daily (later stopped due to low blood sugar levels); clopidogrel 75 mg; quinine sulphate 200 mg; ranitidine 150 mg twice daily; folic acid 5mg; and digoxin 125mcg.

In the Rehabilitation and Assessment Directorate (RAD), the assumption was that our patient had suffered a stroke causing a right-sided weakness, as per the handover pre-transfer, however, further neurological features were detected on the post-take ward round as listed below: right lower motor neurone seventh nerve weakness; ptosis right greater than left; bilateral wrist drop; bilateral foot drop; generalized reduced tone and reduced power in all four limbs: right arm 3 out of 5, right leg 0 out of 5, left arm 3 to 4 out of 5, and left leg 2 out of 5. No comment was documented regarding sensation.

The chronicity of the neurological features was uncertain at this point as they did not appear to have been previously documented and the immediate reaction was to exclude an acute neurological process. Fortunately, her daughter was present during the ward round that day and a collateral history revealed our patient had ‘possibly’ been like this for 18 months or more. This led to a degree of reassurance with regard to the fact that the neurological findings were unlikely to be acute.

Further discussion with our patient’s son confirmed that her mobility had gradually deteriorated over a two-year period; from his perception, the only novel finding was alteration of our patient’s speech at the time of a presumed ischemic stroke.

Given the account from our patient’s son and daughter, her general practitioner (GP) was also contacted and it was reported that our patient had been referred to various disciplines for poor mobility but had failed to attend her appointments; she had been diagnosed with a Bell’s palsy and third nerve palsy in 2011, which had been attributed to her diabetes. Interestingly, a previous trial of steroids from her GP for presumed arthropathy had resulted in clinical improvement.

Our patient underwent several investigations, included below, as part of the investigative and diagnostic process. In addition, for the complete history, her blood pressure was 104/53 mmHg and heart rate was 57 beats/minute with no documented murmurs.

A magnetic resonance imaging (MRI) brain scan showed atrophy with small vessel disease, high signal at the left corona radiata and adjacent left occipital horn. An MRI cervical spine scan revealed no gross abnormality and a CT scan of her abdomen and pelvis showed extensive diverticular disease only.

Blood investigations

Blood tests showed her Hb level was 85g/dL; WCC was 11.1; platelets were 512, MCV was 89 and her hematinics were normal. Urea and electrolytes test (U&E), liver function test (LFT), and calcium test results were normal. Her albumin level was l0, CRP level was 120 and her baseline HBA1c level was 57mmol/L (normal range 20 to 42mmol/L). Her cholesterol level was unavailable and her blood and urine cultures were negative.

Vasculitic screen

Her antinuclear antibody test (ANA) results were 1/40 and showed a speckled pattern. She had low C3 0.71g/L (0.88 to 1.82g/L) and low C4 0.08g/L (0.16 to 0.45g/L). Her rheumatoid factor was 623, antineutrophil cytoplasmic antibody (cANCA) results were strongly positive and myeloperoxidase / proteinase 3 (MPO/PR3) negative. Her immunoglobulin A (IgA) level was 6.5, erythrocyte sedimentation rate (ESR) 115, and cryoglobulins were negative. Her carcinoembryonic antigen (CEA) and serum angiotensin-converting enzyme (ACE) levels were normal, and CA 125 test result was 70 (0 to 35). Serum electrophoresis showed no paraproteins and her neuroimmunological blood test results were negative.

Invasive investigations

Her lumbar puncture test result was negative.

Neurology unit investigations

Electromyography (EMG) showed severe axonal sensory motor neuropathy.

Multi-specialist input from several disciplines including rheumatology and neurology was also requested.

The neurologist documented the following clinical findings: right ptosis; right facial weakness; generalized weakness right greater than left; profound distal greater than proximal weakness and wasting left greater than right; upper limb greater than lower limb; sensation distally decreased in lower limbs; and areflexia.

The general consensus was that our patient was probably manifesting a peripheral neuropathy secondary to a vasculitis (the type of which was difficult to classify); the neuropathy had been possibly exacerbated by a recent stroke; the stroke may have been part of the vasculitic process itself or could have been related to atrial fibrillation.

It was felt that a nerve biopsy would have little else to contribute to the diagnosis and simultaneously might induce patient distress and was therefore avoided.

Given her history of T2DM, our patient was cautiously commenced on a trial of prednisolone 40mg with azathioprine on 13 September 2013; additional oral antidiabetic therapy on advice of the diabetic team was commenced and gradual step-down of steroid therapy was planned.

Within days of steroid initiation, our patient’s inflammatory markers improved. Her CRP level fell to 36 and her WCC to single figures.

Her right wrist drop showed slight improvement from initial investigations to the point of discharge. There was, however, little neurological and functional improvement otherwise.

Our patient remained bedbound and her hospital stay was complicated by a pressure ulcer, which had completely healed prior to discharge to a care home six months later. On discharge her blood test results revealed Hb of 94, WCC of 11.5, her platelets were 380 and MCV 90.8, her CRP level was 20 and albumin level was 28. She remained clinically stable and her treatment goal was to help prevent any further neurological deterioration.

Our patient had been admitted for investigation of iron deficiency anemia and suffered recurrent illness during admission precipitating a prolonged hospital admission and eventual transfer to her local hospital for stroke rehabilitation.

Looking back at the case, our patient did have a stroke as was confirmed on MRI; however, the fact that she had bilateral and long-standing neurological signs evaded detection for a considerable period of time.

It is only after a thorough history-taking, examination and comprehensive geriatric assessment post transfer to the rehabilitation unit that her illness was diagnosed. Though there may not have been a great change to her overall quality of life, an underlying debilitating diagnosis was established with a treatment goal attempting to prevent further neurological deterioration.

It can be argued that had a comprehensive geriatric assessment taken place earlier, keeping in mind that she had displayed neurological symptoms some 18 months previously, would earlier initiation of treatment been more effective in improving her quality of life? Should the fact that she had failed to attend appointments prompted further thinking as to the underlying factor causing nonattendance at clinic appointments, keeping in mind that there was a history of neurological signs?

The case aims to highlight the importance of taking a good history and performing a comprehensive assessment, especially in the older adult [ 1 ].

Written informed consent was obtained from the patient’s daughter for publication of clinical details and this case report. The patient verbally consented to publication of the case report but was unable to sign the document due to her wrist drop. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Abbreviations

angiotensin-converting enzyme

antinuclear antibody

antineutrophil cytoplasmic antibody

carcinoembryonic antigen

chronic obstructive airways disease

C- reactive protein

computed tomography

CT pulmonary angiogram

electromyography

erythrocyte sedimentation rate

gastrointestinal

general practitioner

immunoglobulin A

liver function test

mean cell volume

myeloperoxidase/proteinase 3

magnetic resonance imaging

Rehabilitation and Assessment Directorate

type 2 diabetes mellitus

urea and electrolytes test

white cell count

Martin F. Comprehensive assessment of the frail older patient. British Geriatrics Society. http://www.bgs.org.uk . Accessed November 2014.

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Acknowledgements

A special thank you to Dr Medhat Zaida, Dr Martin Perry, Dr Tracy Baird, Dr Neil McGowan for providing their valuable input and support in the diagnosis and management of this case. A big thanks to Dr Iain Keith, Dr Christopher Foster and also to Dr Gautamananda Ray for providing their valuable opinion when the manuscript was being drafted and a special thanks to all the other medical, nursing and allied health professionals involved in our patient’s care.

Author information

Authors and affiliations.

Acute Medicine Registrar, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries, DG1 4AP, UK

Durga Ghosh

Vale of Leven District General Hospital, Main Street, Alexandria, G83 0UA, UK

Premalatha Karunaratne

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Corresponding author

Correspondence to Durga Ghosh .

Additional information

Competing interests.

The authors declare that they have no competing interests.

Authors’ contributions

DG was the locum registrar involved with management of the patient, initiating and carrying out investigations during admission, making specialist referrals, liaising with other specialities, acquiring data, drafting and designing the manuscript. PK was the consultant under whom our patient’s care was allocated. PK was also involved in initiating investigations during admission, liaising with other specialities, acquiring data, drafting and designing the manuscript. Both authors read and approved the final manuscript.

Authors’ information

Dr Durga Ghosh, ST4 Acute Medicine, Dumfries and Galloway Royal Infirmary, Dumfries Dr Premalatha Karunaratne, Consultant Physician Medicine for the Elderly, Vale of Leven District General Hospital, Alexandria and Royal Alexandra Hospital, Paisley.

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Ghosh, D., Karunaratne, P. The importance of good history taking: a case report. J Med Case Reports 9 , 97 (2015). https://doi.org/10.1186/s13256-015-0559-y

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Received : 21 January 2015

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Published : 30 April 2015

DOI : https://doi.org/10.1186/s13256-015-0559-y

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Case Study: History Taking

Jenna Robertson, MA, RM

You are meeting Edie for her history and physical appointment. She arrives to the appointment alone. She is a 32 year-old G1P0 and she presents as a cisgender, femme woman. The first section of the Ontario Perinatal Record asks for information about the pregnant person’s partner.

How can you greet Edie and ask her questions about her partner in a way that is in inclusive of 2SLGBTQI folks and also acknowledges that not every pregnant person has a partner?

“Hi Edie, welcome to our clinic. I’m going to be asking you a lot of questions today as we go through your history. Can I start by asking if you have a partner in this pregnancy?”

By asking “do you have a partner” instead of “what is your partner’s name,” the midwife is leaving space for clients who are un-partnered during pregnancy.

Edie answers that yes she has a partner.

How do you ask questions about Edie’s partner without making any assumptions about the partner’s gender?

“What is their name?” Using they/their pronouns to ask about a client’s partner until the client has identified the gender of their partner allows space for the client to name their partner’s gender without asking direct questions. Once the client names their partner, the midwife can refer to the partner by name only, avoiding pronouns until the client names the partner’s gender.

Once the client names her partner’s gender the midwife can mirror the language the client is using to refer to her partner. Asking follow-up questions about other partners can start to open the conversation toward sexual orientation and also avoids assumptions that pregnant people are monogamous and acknowledges the existence of poly relationships.

Sexual Orientation: The new version of the Ontario Perinatal Record (OPR) has space to ask about sexual orientation. Learning about a client’s sexual orientation is important in addition to gaining information about the client’s current partner. Many queer or bi women present in pregnancy in relationships with cis men. Without careful history taking their queer identity may be erased during their time in midwifery care. This erasure may lead to feelings of anxiety or depression. Midwives should avoid the assumption that clients are heterosexual, even when they present to care in heterosexual relationships. Questions like “is Viviane your only sexual partner at this time?” and follow-up questions about sexual history like, “Do you know what the term ‘sexual orientation’ means?” “Can you tell me about how you identify your sexual orientation?” “Can you tell me if you have had sexual relationships with men, women, or both?” can help the midwife to establish an accurate sexual history. Note that many people will identify as straight when asked even if they have had/are having same-sex relationships, so asking varied questions, and asking specifically about sexual history and not just sexual orientation is important.

Gender Identity: Unfortunately neither the new nor the old OPR has space for noting the gender identity of clients or their partner(s). However, midwives can be attentive to using gender-neutral language, mimicking the language and pronouns used by clients and their partners, and asking direct questions about gender identity. Midwives should avoid the assumption that midwifery clients and their partners are cisgender.

How can you ask questions about how the pregnancy was conceived without making any assumptions about the origin of the gametes?

Questions like: “Did you use any fertility treatments to conceive this pregnancy,” can get the conversation started for 2SLGBTQI clients and for straight clients alike, but if no fertility treatments were used then the midwife will need to keep asking open-ended questions in order to elicit a complete history.

External Link

Families are coming to midwifery clinics in all kinds of shapes and sizes. Midwives in Ontario should be familiar with the Bill 137, also known as “Cy & Ruby’s Law”:  http://www.ontla.on.ca/web/bills/bills_detail.do?locale=en&BillID=3554

Midwives should avoid assumptions about the gender of the people sitting in their clinic rooms and even avoid assumptions about which partner is the pregnant client. A couple may present as a straight, cis appearing couple, but the couple may include a trans man who is the pregnant client and not his cis, female partner. History taking that uses inclusive, open-ended language benefits all clients (cis & trans, queer and straight) because an open-ended approach to history taking leaves space for all clients to honestly share their stories so that as care providers, midwives get the most complete and most accurate information and also begin to build trust with clients from the first clinical encounter.

Case Study: History Taking Copyright © 2017 by Jenna Robertson, MA, RM is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Case history-taking: Hearing the patient’s story

5 Case history-taking Hearing the patient’s story Chapter Contents General considerations Taking the history Summary of the aims of history-taking The history of the case history The ‘conversation’ The nature of history Clinical hermeneutics Narrative-based medicine On hearing, speaking, moving and recording Posing questions and listening to replies Ask for more information   229 Seek clarification   230 Use echoing (repetition)   230 Share thoughts   230 Summarize   230 Interrupt   232 Use silence   233 Use humour and play   234 Questioning style Keep questions separate   236 Keep questions simple and clear   236 Proceed from open to closed questioning   236 Avoid leading questions   239 Non-verbal questions   240 The consultation environment Children The older patient Using intuition Assessing the four aspects of being The six non-naturals and the prioritization of the individual History formats Opening questions Opening answers Follow-up consultations Preparation Enactment ‘By the way …’ Four territories Change and recollection The initial consultation The blank sheet To be continued … Questioning prior conceptions Recognizing limitations Complexity, non-linearity and flexibility Welcoming Personal details Patient’s name   275 Address   275 Preferred contact telephone number   276 Date of birth   276 Gender   277 Occupation   277 Relationship status   278 Children   279 Who lives at home?   280 GP details   281 ‘How did you hear about me?’   281 Personal details leading into the history Phytotherapy orientation The presenting complaint History of the presenting complaint Expectations 1 Previous medical and life history: sensitivity to initial conditions Allergies, intolerances or sensitivities Family history Drug and treatment history Social history Smoking   290 Alcohol   291 Illicit substances   294 Exercise and relaxation   295 Interests and pastimes   297 Home or/and working life   297 Vitality Energetic assessment Temperament, personality, mood and outlook Personal style Diet Dietary intake and pattern of eating   307 General dietary factors   308 Food history   310 Financial limitations   310 Systems enquiry Digestive system   311 Urinary system   312 Integumentary system (skin, hair and nails)   312 Musculoskeletal system   313 Cardiovascular system   314 Respiratory system   314 Immune system   314 Nervous system   315 Reproductive system   315 Comprehensive versus comprehension Expectations 2 and transiting to the physical examination General Considerations Taking the History Case history-taking, as we discussed in the previous chapter, is the key means of getting to know the patient. The majority of diagnoses in phytotherapy, conventional medicine and many other modalities are based principally on the case history. For example, Peterson et al. (1992 ), studying medical doctors, found that in 76% of cases: ‘the leading diagnosis after taking the history agreed with the diagnosis accepted at the time the record was reviewed two months after the initial visit’. Yet, despite its central importance, in conventional medical practice, it has been suggested that ‘skilled history-taking is in danger of becoming a lost art’ ( Schechter et al. 1996 ). We can propose that this is likely to be primarily due to biomedicine’s emphasis on acute medicine (where history-taking tends to be pointed and abbreviated) and over-emphasis (leading to over-reliance) on investigative technology. Herbal practice remains a place where the case history is accorded central importance and where adequate space is made available for its exploration. This is in part because herbal practice has been less occupied with acute medicine and more focussed on chronicity (especially since around the mid-twentieth century) and the attendant need of the chronically ill patient for more profound personal exploration of their predicament; and since herbal practice has been excluded from mainstream medicine it has not had direct access to, and therefore has not become excessively entangled with, technological methods of patient exploration. Regardless of the orientation of one’s therapeutic discipline towards it, however, history-taking remains a tricky art. Students are generally exhorted to ‘maintain objectivity’ and ‘keep a clinical distance’, while engaging with the patient’s story but such directions represent forlorn hopes raised to protect against the fact that case taking is a subjective phenomena and therefore a suspect area of activity viewed from the perspective of positivistic medical science (and this is another reason why history-taking is a threatened species in biomedicine). So we need to ask whether a history can ever be ‘taken’ as if it existed as a solid object that can be ‘extracted’ ( Note : it is common for clinical texts to purport to instruct students on how to ‘extract the history’) from the patient and then held up to the light for analysis. To ‘take’ or ‘extract’ a history is to de-contextualize it and risks rendering it an insipid and flimsy simulacrum – great care needs to be taken when basing clinical decisions on such an untrue-to-life creature. Rather the practitioner needs to be aware of the fact that she cannot help but be actively involved in building, constructing and creating the ‘case history’. The case history, as written, is an artefact, and one that usually requires interpretation when being exhibited to others – even colleagues trained in the same style of questioning and documenting. One practitioner’s precise clinical record is another’s incomprehensible screed. The practitioner is involved in the construction and presentation of the patient’s history of necessity and this fact should be negotiated rather than resisted. The practitioner cannot help but set the patient’s story within her own frame of reference, which is based on her theoretical and clinical training, personal history (early education, parental influence, etc.), political bias, social status, cultural milieu and so forth. In other words, since the practitioner cannot be other than who she is , then the limits to her capacity to comprehend patient’s stories are set by the expansiveness and subtlety of her worldview. The greater the practitioner’s own fund of experiences and stories, and the greater her degree of subtlety of thought, the broader will be her capacity to appreciate the experiences and stories of her patients. The practitioner’s formative influences and inner and outer journeys determine her ability to leave the history in the context of the whole patient as opposed to taking it from them. This is analogous to the herbal practitioner’s insistence on leaving active phytochemicals within the context of the whole plant (amidst a mass of material that is indeterminate or only partially appreciated) rather than extracting isolated active constituents (in order to only deal with factors that are precisely and concretely known). As the practitioner is ‘taking the history’, she is selecting, editing, omitting, mishearing, ‘overhearing’, interpreting and developing the patient’s picture – by all these means, she constructs a version of events and builds a thesis regarding their significance and meaning. While direction of the patient in this process can be minimized (e.g. by posing ‘open’ questions and avoiding ‘leading’ ones; see below), it cannot be eradicated. Even with the greatest awareness of the various issues involved the practitioner cannot be aware of every factor in the clinical encounter that adapts the way that the patient tells her story, nor, even with identification of the issues, can she change (or predict the impact of) some of these, e.g. the practitioner’s gender, skin colour, accent, age, etc. Histories are not consistent entities, they change in the telling and retelling and depending on the audience. Patients may discover new insights as they tell their story (a desirable and often therapeutic outcome that should be one of the key goals of history-taking) but alternatively, they may mechanically repeat an oft-told and negatively reinforced self-tale (a scenario to be detected and challenged), or creatively ‘play’ with adding new elements to the storyline to see if they fit or to ‘play tricks’ on the practitioner (strategies that may confuse or mislead the practitioner if they are not picked up on). So then, the case history is a fascinating, if slippery, place to visit; let us go and take a look around … Summary of the Aims of History-Taking Since we have discussed many of the concepts and issues related to the aims of history-taking in the phytotherapy consultation in previous chapters, we need only briefly state them at this stage: • Enabling patients to reflect on their predicament and to: Identify key themes and issues Gain insight into their situation Explore the meaning of their situation Develop a more coherent sense of self • Allow the practitioner to provide assistance in: Bearing witness Conveying human warmth and care Facilitate self-discovery and self-development • Access information to help form a diagnosis (less important in follow-up consultations) • Determine areas that stand in need of: Support Care Learning Treatment • Elucidate areas where referral is indicated. The History of the Case History Epstein et al. (1997 ) maintain that: ‘For generations, there has been little change in the method of recording information from the history’, but is such an argument sustainable? Certainly the ‘method of recording’ has changed dramatically, at least in biomedicine, in that patient records are now computerized, although we will save discussing the intrusion of the computer as the ‘third person in the consulting room’ for later. I take Epstein to mean, however, that the process of taking the history is little changed, but again this is hard to credit. As doctors have moved from the bedside to being desk-bound, there has also been a shift of location of emphasis from the context of patient (represented by ‘bed’: resting, sleeping, dreaming, copulating) to that of doctor (’desk’: acting, writing, filing, working). Factors such as the means by which information is recorded and the setting in which information is obtained affect the conduct and content of the consultation itself, including history-taking. We should not assume, despite the emphasis placed on the importance of the history at the beginning of this chapter, that the ‘case history’ – meaning a verbal dialogue between patient and practitioner – has always been the dominant means of knowing the patient or that ‘case history’ has always equated to ‘verbal dialogue’. Kuriyama (1999 ) provides an alternative perspective: In the second century B.C.E., in the earliest case histories of China, the sick summon Chunyu Yi not with vague pleas for succor, but with the specific wish that he come and feel their pulse. And that is just what the great doctor does. In each case, he arrives, straightaway grasps the pulse, then prescribes a remedy, explaining, ‘The way I knew the ailment is that when I felt the pulse …’ As if it were all a ritual, and his role was that of pulse interpreter. Primary focus on the pulse was not limited to China but, based on the pronouncements of Galen, dominated diagnosis in the west until recent centuries. Kuriyama names the four ways of assessing patients used in ancient Chinese medicine as: ‘gazing ( wang ); listening and smelling ( wen ); questioning ( wen ); and touching ( qie )’, but asserts that ‘in practice … attentions concentrated mainly on qiemo , palpating the mo ’. Mo can be translated as (but without being limited to) blood vessels or pulse . This focus on the pulse contrasts with the diagnostic hierarchy outlined in various classic Chinese medicine texts described by Kuriyama. For example in the Nanjing : … to gaze and know the illness is ‘divine’ ( shen ), to know by listening or smelling is ‘sagely’ ( sheng ), to question and know was ‘crafty’ ( gong ), to touch and know only ‘skillful’ ( qiao ). Whereas the Shanghanlun ‘was blunt: the physician who knew by gazing belonged to the top class ( shanggong ); the physician who questioned and knew was average ( zhonggong ); the physician who touched and knew was inferior ( xiagong )’. Kuriyama concludes that: ‘Mastery of medicine was defined first by an exceptional eye’, and proceeds to discuss the subtleties of what was represented by the concept of the diagnostic ‘eye’ and the ‘gaze’. We might consider the progression of this emphasis on visual knowing to extend through X-ray machines to MRI scanners though the notion of the doctor’s ability to ‘see inside’ the patient is an ancient one. Commenting on the case reports collected in the Hippocratic Epidemics , Nutton (2004 ) observes that the authors ‘are already selective in their presentation of signs and symptoms, focussing in particular on things that would, in future, enable the writer (and later his audience) to estimate the severity of a similar condition, forecast its outcome and, where possible, intervene successfully’. Nutton lists the relationships and features associated with disease described in the case histories in Epidemics 1 : … the common nature of all things and the particular nature of the individual; the disease and the patient; the regimen prescribed and the prescriber; the constitution of the heavens and the region, in general and in particular; the custom, way of life, practices and age; talk, manner, silence, thoughts, sleeping or not; dreams, plucking, scratching, tearing; exacerbations, stools, urines, sputa, vomit; the stages of a disease, and its potential for crisis and death; sweat, rigor, chill, cough, sneezes, hiccoughs, flatulence, haemorrhoids and haemorrhages. Behind all this lies shrewd, careful and accurate observation, using all the senses. Yet these are reports dealing with acute cases and we hear fewer stories regarding chronicity from ancient medical texts, partly because, as Nutton explains: ‘given the age structure of the population, the degenerative diseases characteristic of the twentieth century will have been fewer in number’, and partly due to a different conceptualization of disease, in that ‘ancient doctors saw the gradual physical and mental deterioration of old age as part of an inevitable process’ so that consequently, ‘it is not the infirm we hear of, but the exceptions, the hale and hearty, like the Elder Pliny’s centenarian friend Antonius Castor, still pottering around his herb garden’. Nutton points out the importance of prognostic ability in early Greek doctors, as a means of establishing trust in their capacities. Prognostic skill was a means by which the doctor ‘could establish his credentials and, at the same time, protect himself against accusations of malpractice. By being able to predict the likely outcome of a disease … he could gain obvious credit for a cure … [but] should the patient die, he had a strong defence if he had already announced that this was a likely outcome’. An emphasis on prognosis then served as a ‘tactical’ strategy regarding ‘both advertising and insurance’ but was not limited to these goals since it was also ‘essential to the understanding and treatment of the individual patient, ensuring that whatever is prescribed will be appropriate for that patient’. Furthermore, ‘the doctor who professes the art of prognosis declares that his particular technique deals with the past, present and future of his patient, a bold claim incorporating what today would be termed obtaining the case history, diagnosis and prognosis’. This attempt to stand in the present and yet be able to look backwards and forwards in time continues to be one of the hallmarks of the clinician but also constitutes one of the key characteristics of the shaman. ‘Shaman’ can be translated as ‘one who knows’ (or ‘clever fella’ as McKenna reports) and figures occupying the shamanic role typically act simultaneously as repositories of the history of the tribal group; authorities on the present; and seers who are able to predict future events. Healthcare practitioners, then, partake in a shamanic tradition at least in being accorded the status of possessing an uncommon temporal facility. The origin of case history-taking in the consultation then might be extended back to shamanism in archaic cultures. The case history represents a gathering together of information about the past and the present in order to be able to see into, and to make predictions about, the future. The current emphasis in conventional medicine on diagnosis, prognosis and acute cases therefore does not represent a particularly recent trend. However, the reliance on technology and the extent to which the individual personal characteristics of the patient are excluded from consideration do signify breaks with a long medical tradition and are major current influences preventing mainstream medicine from adapting to meet the requirements necessitated by the shift in burden from acute to chronic disease. Current mainstream medical methods of assessing past impacts, present influences and future likelihoods, including imaging technology and genetic testing could be considered as a concretization of archaic visionary capacities or as phenomena emerging within an ancient project. The major concern surrounding the point now reached has to do with the extent to which this continuum has shot beyond the human dimension to a place where the patient is viewed differently – de-personalized and disembodied. The relationship between herbal medicine and shamanism is profound but complex. In ancient indigenous cultures, the possession of substantial personal knowledge of the healing properties of a wide range of plants is commonplace and tends to be seen as ordinary or basic knowledge that is therefore considered unremarkable, although some people have greater knowledge than others and are accorded ‘practitioner’ status. Lenaerts (2006 ) studied the Asheninka people who live on the Peru–Brazil border and found a distinction in that: ‘Shamans are deemed to have a superior knowledge, since they are able to heal illnesses that ordinary people or herbalists cannot’ although herbalism and shamanism do not represent ‘two specialized, separate fields of healing, (rather) they form two distinct expressions of the same issues’ [original emphasis]. The shaman’s advantage does not rest in his superior knowledge of plants (in fact Lenaerts suggests that, in some cultures at least, the shaman may know less about healing plants than other types of healers) but rather in his status as a ‘specialist in relationships with other beings’. The Asheninka shaman is able, with the assistance of ingested ‘entheogenic’ plants ( entheogen means ‘God generated within’, and is an alternative way of viewing and describing so-called ‘hallucinogenic’ plants) to meet other beings such as plants, animals and stones as people . Discourse with these beings can lead (among other things) to diagnostic insights and the subsequent implementation of therapeutic strategies. Such encounters also give rise to creation stories, human–environment relationship schemas and rationales for the interpretation of experiences. They are the source of philosophies, religions and medical systems and they unify and hold together the distinct cultures that the agglomeration of these elements give rise to. We are engaged here with the construction and interpretation of worlds, plunged into the matrix of myth, story, saga, fairy-story, morality-play and ‘case history’ that spin out of this generative centre. Although it may seem at this point that we have travelled a long way in this chapter, and very quickly, the suggestion remains that if we follow the thread of what the case history actually is (i.e. an attempt to temporally comprehend one person, to understand their predicament and to discern ways of assisting them), back far enough it will lead us to the root of art, science, philosophy and medicine that resides in the person of the shaman and in the presence of the entheogen. It is difficult to perceive the sacred worldview from the perspective attending that of the profane but the shaman and the physician share a common origin. Both are ‘ones who know’ and what they know has to do with nature – they know the nature of nature . In origin and essence both encompass the roles of artist, scientist, philosopher and healer. Although the scope of the physician (whether phytotherapist, doctor or other) has diminished to the generic mediocrity of ‘healthcare practitioner’, the territory and the possibility of the shaman remain available and are accessible through means of ‘taking the history’, since the case history is the place where all our stories come together and where time travel is the mandatory mode of transport. The ‘Conversation’ Referring to the ‘case history’ may seem somewhat inadequate to the task of describing a way of looking that includes assessment of the present and speculation about the future, since ‘history’ is commonly perceived as referring to the study of what is past. Collins English Dictionary (2000 ) describes ‘history’ as deriving from ‘Latin historia , from Greek: enquiry, from historein to narrate, from histor judge’ and gives one definition of history as a: ‘Narrative relating the events of a character’s life’. Enquiry, narrative, events, judgement – these are all features of the consultation that can easily be identified with the case history. Churchill’s Medical Dictionary (1989 ) defines the case history blandly as: ‘A recording of information relating to a particular case …’. This view, emphasizing the production of a historical record by a neutral observer, lacks any sense of the assessment and dynamic interplay that occurs during the process of history-taking – of what the practitioner gives to the encounter alongside what she takes away from it. So perhaps there is a better term to describe the question and answer session that transpires during the consultation, and which, in contemporary phytotherapy at least, forms its most significant part? It was the convention in medical textbooks on clinical examination until recent times to describe it as ‘the interrogation’ (e.g. Hunter & Bomford 1956 ; Macleod 1967 ). This term refers to formal and detailed questioning but it also suggests aggression and its use in medicine is now hard to countenance since the word ‘interrogation’ is inextricably linked with a visual image of a bright light being shone into one’s face. The negative associations we have with the concept of interrogation are disturbing, since we now connect the word with torture. Many authors have described and considered the history of, and continuing involvement between, medicine and torture (e.g. Maio 2001 ; Lifton 2004 ; Klein 2007 ). A recent questionnaire-based study ( Bean et al. 2008 ) exploring the attitudes of one population of American medical students (336 students at the University of Illinois College of Medicine) to the ‘permissibility and ethics of the use of torture’ found that ‘35 percent of students agreed that torture could be “condoned” under some circumstances. Moreover, 24 percent … disagreed that torture should “be prohibited” as a matter of state policy and a similar 24 percent disagreed that torture was “intrinsically wrong”’. This is a hugely complex as well as troubling area but we may suggest that an excessive, indeed a pathological, emphasis on objectivity and clinical distance is one amongst a number of underlying factors that enable medical torture. If objectivity extends to the objectification of bodies, and if clinical distance ranges to the point where human connection and feeling is lost, then some of the conditions in which unforced torture can be conducted are set. Clinicians are still encouraged to ‘put the spotlight on the patient’ and ‘keep yourself out of the picture’ but we should remain aware of the double reading that is possible when this type of language is used. More recent textbooks on clinical examination have tended to refer to history-taking as ‘the interview’. This can be read as an attempt to retain the formality and the objectivity/neutrality of the practitioner implicit in the use of ‘interrogation’ while losing the negative correlations that word now gives rise to. The move from ‘interrogation’ to ‘interview’ also represents a shift from the practitioner as ‘policeman’ to the practitioner as ‘manager’. To be interviewed is to be cast in the role of applicant or news item. The practitioner-as-interviewer has a power role where she can: • Act as a manager in approving the patient’s application (‘following a successful interview’) to be a sick person by conferring a diagnosis and a course of treatment to be followed • Act as a journalist in taking the patient’s information and spinning it into a (more or less reliable) story. In this role we can see the short conventional medicine consultation as a form of rushed TV interviewing where only pre-formulated sound-bites can register and a nuanced discussion of the complexity and multidimensionality of a given issue is impossible. Some clinicians have suggested the use of ‘conversation’ (e.g. Kaplan 2001 ), which is certainly informal and devoid of unpleasant connotations but seems a little, well, aimless and insipid. We know that a lot of conversations ‘don’t go anywhere’, that people tend to make ‘polite conversation’ and do things ‘just for the sake of’ conversation. Perhaps it would help if we medicalized it by calling it the ‘clinical conversation’? Or therapized it by calling it the ‘therapeutic conversation’? Or how about we try something else – the ‘discussion’ anybody? Perhaps, after all, ‘the history’ still works best since it suggests a comprehensive view and implies an attempt to take in and make sense of the big picture. In which case, it may be helpful to explore the notion of ‘history’ as applied to the consultation in a little more detail. The Nature of History The way that history is practised varies but the archetypal model reflects the dominant scientific values of contemporary western culture. This type of history is based on objectivity, chronology and classification. Complex, sinuous themes and elliptical notions are forced into ill-fitting (and sometimes delusional) categories such as that of ‘the baroque period’ or ‘the scientific revolution’. Other forms of historical method focus more on contextualization and interpretation but even here the preference is to begin deconstructive work on what purport to be finished objects. The patient represents history-in-process and only becomes a finished project when the heart stops beating – a study option that is not consistent with the aims of the clinician! Gadamer (1989 ) addresses the issue of historical analysis and its temporal separation from its topic of study, commenting with reference to works of art. He recognizes that in historical studies, it is generally believed that: ‘objective knowledge can be achieved only if there has been a certain historical distance’ from the creation of the object, and maintains that ‘it is true that what a thing has to say, its intrinsic content, first appears only after it is divorced from the fleeting circumstances that first gave rise to it’. A person is not a ‘thing’ and does not materially endure for long, although the same could be said of ‘the baroque period’ or ‘the enlightenment’ and yet, these continue to be topics of historical study. We can consider previous events in the patient’s life (or their ‘previous medical history’) to represent ‘things’, however – at the time of the consultation the patient may have achieved enough distance from the event for it to be open to analysis and be capable of yielding its ‘intrinsic content’. Yet the practitioner is frequently trying to make sense of events as they happen, to make sense of ‘fleeting circumstances’ especially in acute medicine. At these times it is necessary to make the best judgement one can and then to keep that assessment continually open to revision. Gadamer (1989 ) further describes the dominant historical perspective: The positive conditions of historical understanding include the relative closure of a historical event, which allows us to view it as a whole, and its distance from contemporary opinions concerning its import. The implicit presumption of historical method, then, is that the permanent significance of something can first be known objectively only when it belongs to a closed context – in other words, when it is dead enough to have only historical interest. In terms of living patients, ‘relative closure’ is the only type of closure available and it will rarely be possible to gain much distance from ‘contemporary opinions’; such an achievement is only attainable when we view events-as-things in older patients where sufficient sociocultural and medical change may have occurred within one lifetime for that event to be viewed differently (as has happened with, e.g. HIV/AIDS). Even then we can never be certain that this ‘different view’ represents the definitive, ultimate, true or truest view – it can only appear to be relatively such. Let us return once more to Gadamer as he criticizes the historical method previously outlined, saying that it represents a paradox since: … the discovery of the true meaning of a text or a work of art is never finished; it is in fact an infinite process. Not only are fresh sources of error constantly excluded, so that all kinds of things are filtered out that obscure the true meaning; but new sources of understanding are continually emerging that reveal unsuspected elements of meaning. The temporal distance that performs the filtering process is not fixed, but is itself undergoing constant movement and extension. The same argument holds for people and it well describes the potentiality of practice – to increasingly discover the self and discern enhanced meaning. It also holds for texts about those no longer living. Consider the ways that successive biographies written about people (e.g. Joan of Arc, Napoleon, Bernard Shaw, Sylvia Pankhurst, Orson Welles) follow the process described by Gadamer. Each successive work (if it is any good/worth reading) filters what was previously known, finds new information and arrives at new meanings and each new biography reflects the time it was written in. There is no closure, then, on a remembered life long after it has been lived just as the same is true of life as it is being lived . There is no closure, only a state of natural chaos fluxing with the eternal emergence of new phenomena. The search for absolute objectivity in the human case history constitutes the pursuit of an unrealizable goal that should therefore be abandoned. Rather the practitioner ought to relish the challenges and breakthroughs that result from engaging dynamically with the contingent, latent and emergent worlds of patients, learning to work with relative wholes and testing theories and refining approaches in the light of feedback. In the introduction to their exceptional book looking at emotions and their connections with the ‘histories of art, music and medicine’ Gouk and Hills (2005 ) describe an approach to the practice of history that fits with, and contains insights for, that pertaining to the taking of the case history: The essays collected here do not, and of course could not, constitute a chronological or geographical survey of the representation of emotions in Western Europe since the Greeks. More significantly, we have not privileged those historical conjunctions conventionally identified as crucial for changing patterns in emotional articulation (for instance, the Ancient World, the medieval era and the eighteenth century), nor singled out those thinkers most usually credited with formulating new approaches (e.g. Plato, Aristotle, Augustine, Descartes, Le Brun, Spinoza, Rousseau, Voltaire). Instead, our principal aim has been to focus the investigative spotlight on specific moments when one formulation of emotions conflicts or converges with another, or when gaps or ellipses in one discourse on emotion are illuminated by another. In adopting this dual approach, we draw attention both to the necessarily non-disciplinary ways in which emotions have been conceived and to the complex processes by which some ideas eventually achieve authoritative status while others wither, neglected. With a little work, the above could be adapted to form a manifesto for the holistic case history, one especially suited to chronic pictures, bearing in mind the points made in the previous chapter and given that: • Chronological and geographical considerations are similarly difficult in the consultation – recall the non-chronological chaos narrative and the difficulty of anatomically locating conditions such as chronic fatigue syndrome. • It is important to avoid privileging one particular model or authority in conducting the consultation lest one’s ability to work synthetically and see creatively is impeded. • We could use identical language to describe one of the primary aims of the case history as being to: ‘focus the investigative spotlight on specific moments when one formulation of emotions conflicts or converges with another, or when gaps or ellipses in one discourse on emotion are illuminated by another’. This statement of intent has even wider utility if, in place of ‘emotions’ we broaden the remit to ‘emotions/symptoms/stories’. • This approach is better suited to detecting which features, aspects and themes in the patient’s picture are of greatest significance and which are less deserving of attention. Foucault (1963 ) has distinguished between the ‘historical’ and ‘philosophical’ perception of disease. Here, ‘history’ has to do with such matters as the symptoms and course of the disease whereas the philosophical approach calls ‘into question the origin, the principle, the causes of disease’. In practice these are not separate but rather interweaving lines of thought – as soon as we have some sense of the historical features of the patient’s condition we philosophize as to their meaning. The ebb and flow of this process is strongest in the early part of the consultation where multiple philosophical analyses may be made rapidly and, indeed, intuitively, in response to historical information until the field of options becomes clearer (note that this does not necessarily mean narrower). The practitioner cast as historian, then, needs to be a historian–philosopher; but what use would a historian lacking in philosophy be in any case? Clinical Hermeneutics Leder (1990 ) argues that: ‘clinical medicine can best be understood not as a purified science but as a hermeneutical enterprise: that is, as involved with the interpretation of texts’ and he identifies four textual forms that relate to the consultation: • The ‘experiential text’ of illness as lived out by the patient • The ‘narrative text’ constituted during history-taking • The ‘physical text’ of the patient’s body as objectively examined • The ‘instrumental text’ constructed by diagnostic technologies. Of these, the central two constitute the texts available in the consultation, the last is a subtext that may inform the consultation and the first refers to the patient’s life outside of the consultation. This latter text is the most important to the personal experience of the patient but the least accessible in the consultation – although all three of the other texts can combine to attempt some degree of approximation of it. The narrative text of the case history most particularly represents the practitioner’s effort to appreciate the experiential text of the patient’s lived experience. The history represents the practitioner’s best chance of understanding the patient’s life and its attendant phenomena. How far can/should we take the concept of textual analysis? Leder suggests we should follow the hermeneutical thread a long way down because, at root: ‘certain flaws in modern medicine arise from its refusal of a hermeneutical self-understanding (such that) in seeking to escape all interpretive subjectivity, medicine has threatened to expunge its primary subject – the living, experiencing patient’. The case seems an urgent and crucial one then, except this analysis fails to factor in the substantive rebellion that takes place daily at grassroots level on the part of both patients and practitioners who reject being treated/treating people like automata rather than persons. Churchill (1990 ), however, argues that Leder does not go far enough and that it is insufficient to limit the hermeneutical argument to medicine, it should be extended to recognize that science itself is, at its core, a hermeneutic enterprise. Baron (1990 ) meanwhile queries the notion of the textual metaphor since it ‘runs the risk of conceptualizing patients as more static than they are’ and because it does not fit the characteristics of the consultation in that ‘the qualities of mutuality and determinacy are not those one usually associates with texts’. Baron ends by calling for a different metaphor that captures the uncertainty resident in practitioner’s comprehensions of patients. OK, Baron says, you’ve told us to look at the patient’s texts – but it just doesn’t work like that; that doesn’t fit the reality of the clinical encounter – even if one is well disposed to the hermeneutical way. Churchill (1990 ) argues that it is necessary to question the foundations of medicine and science and discover that they rest on a base that has to do with hermeneutics. Upshur (2002 ) questions the notion of a ‘base’ for the practice of medicine with regard to a discussion of evidence-based medicine (EBM) and suggests that, if we are to talk of bases and foundations, they must be pluralistic in nature. Upshur sees no reason why there should be any ‘sharp conflict between facts and values’ and references medical and scientific theorists who are attempting to overcome this duality. He perceives a growing appreciation of the ‘complex values, perceptions and beliefs that frame how medicine is practised’ and notes that the ‘focus on interpretation, subjectivity, natural language and qualitative methods highlights dimensions of practice that escape the methods of EBM’. Such a focus on combining interpretive approaches ‘is likely to lead a move from the metaphor of a uniform base for medicine as the consideration of the qualitative domain acknowledges multiplicity of perspectives and meanings’. Furthermore, Upshur asserts: ‘medicine and health care are not in need of a single solid foundation, but can operate well in a dynamic emergent framework’ that is woven from these multiple ways of perceiving. This brings us back to the fund of stories that represent the roots of knowing and how we might make sense of these ‘texts’ as they form within and around the individual patient and returns us to Baron’s query about how we can work with patient’s texts in a way that reflects the inter-relational plasticity of the clinical encounter and which takes account of the underlying uncertainties in this dynamic. We can best deal with this by moving on to the next section considering one key interpretive method that can be applied to case history-taking. Narrative-Based Medicine narrative … 1 an account, report, or story, as of events, experiences, etc. 2 … the part of a literary work that relates events … 4 telling a story … Collins English Dictionary (2000 ) Much has been written about which techniques and behaviours constitute ‘communication skills’ and how they can be developed and we will draw on some of this work later in this chapter. We will also discuss the structure of the consultation format and the steps in its enactment in the ‘ History formats ’ section of this chapter. However, regardless of our knowledge and ability in applying such skills, and despite our structural awareness, what we hear in the case history and what we learn from it will be shaped by what we are listening out for (what we are tuned to hear). This tuning is adjusted by what we think are the aims of the consultation and what we think is going on in the case taking. The narrative approach considers that what is essentially occurring in the consultation is a process of storytelling, although this, in itself, tells us little – no more than the blank assertion that patients can be perceived as a collection of texts. What is key to unlocking both of these concepts (history-as-story and history-as-text) lies in the interpretation of these phenomena. Narrative-based medicine represents a contrasting approach to positivistic, deterministic, reductionist medicine in that it is interpretivistic, relativistic, holistic. But stating the case in this way is to suggest a polarity of thought and action that, while it is easy to set on the page (in the ‘text’) does not accurately reflect the reality of practice. Practitioners may, when they think about it (or more commonly when they are asked to think about it) come down on one side or other of an ideological divide between positivism and interpretivism but in the act of practising we tend to be pragmatic. I have already suggested, for instance, that different approaches come into play in dealing with acute and chronic cases. Practitioners in action do not pause to think ‘hmm, shall I take a positivistic or an interpretivistic approach here?’, rather, having an awareness of differing approaches and knowledge of a variety of models and techniques provides options and informs practice. Narrative-based medicine (NBM) is not an alternative to evidence-based medicine (EBM). Patient narratives are a form of evidence just as research represents a type of narrative. If we recall Sackett et al.’s (2000 ) definition of EBM as ‘the integration of best research evidence with clinical expertise and patient values’, then we can easily see NBM as providing us with an appreciation of the patient’s part in this triad but we can also view each element of EBM as a narrative type since each is a text and each is a story: ‘research evidence’, ‘clinical expertise’, ‘patient values’ – all stories. Research evidence is a collection of texts, accounts of (or ‘stories about’) studies conducted with an attempt at objectivity (quantitative research) or subjectivity (qualitative research) with each type being open to (and standing in need of) interpretation. Clinical expertise represents accumulated knowledge and skills in action but which can be assessed and described in the form of texts (supervision and peer-review reports; patient feedback forms; practitioner self-reflection documents and so forth) which tell stories that can be interpreted. Patient values (which I take to mean patient opinions, expectations, preferences, morals, etc.) can be assessed in the case history, written down as text and interpreted. Seen from this perspective, any notion of setting up NBM/EBM as opposing models breaks down and becomes unsustainable – they are in actuality merely different takes on the same stuff . NBM has the potential to be used to scrutinize scientific research evidence and practitioner activity in addition to its usual area of application – the patient’s story. We will shortly move on to focus on this latter domain but need first to point to the practitioner’s involvement with the generation of the patient’s narrative. The way in which stories are told (or performed) in the consultation space, and their content, to varying degrees, is potentially influenced by a number of factors, difficult to exhaustively enumerate and even more difficult to estimate in terms of the extent to which they may have shaped the story. Such factors, on the part of the patient, include: • Topics that the patient does not wish to reveal to the practitioner • Notions about what is allowable and what is not allowed to be said in the consultation • Notions concerning what practitioners want to hear and what they do not want to know about • Opinion on the manner in which information should be expressed in a consultation • Thoughts of the possible implications of revealing or concealing information • Feelings of security and comfort • The extent to which the practitioner is sensed to be actually listening and genuinely interested in the patient and her story • Time: whether the patient feels there is enough time available to express themselves (and whether they have enough time to give to the consultation, e.g. they may be in a rush to get home or to another engagement) • The level of trust the patient feels she can place in the practitioner • The level of ability to communicate: influenced by emotion, inhibition, educational level • External influences: the opinions of others such as family, friends, colleagues and other healthcare practitioners • The patient’s narrative style and bias • ‘Other things’ that are on the patient’s mind, displacing focus on the consultation • The patient’s mood and outlook at the particular time • The extent to which the patient feels well enough and has sufficient energy to fully engage with the consultation. The practitioner has some influence over some of these factors and, through active awareness of them, may be able to modulate them. A simple preamble to the consultation will go a long way, for example: ‘Before we begin let me just say that this is a safe place to talk, we have plenty of time available and I am very interested to know what you really think and feel about your situation’. Of course, one can only convey such signals if they are true (i.e. you really do have enough time) and if you mean them – you really do want to know the patient’s story and are not secretly afraid of ‘opening Pandora’s box’ (or at least not so afraid that it stops you trying). A simple strategy like this will only wield its power if the patient believes you and this will only happen if the statement is genuine. Patient’s know when they are being sold a line and trust is diminished when they feel that this is occurring. The practitioner normally initiates the patient’s storytelling by saying something like: ‘So tell me what you would like help with’. Or: ‘So how have you been since the last visit?’ These simple sentences act as catalysts for the construction of a narrative but they also set an orientation for the way the narrative should begin. This capacity can be utilized by the practitioner to direct the patient specifically or minimally. Consider, for example, an opening line in a follow-up visit where the patient had previously consulted regarding headaches: 1. ‘So how has your headache been since I last saw you?’ 2. ‘So how have you been since I last saw you?’ These are virtually identical but radically different, since the first directs the patient straight to a targeted narrative and the second leaves an open space for the patient to bring in whatever is most significant for them. Line 1 invites the patient into a restitution narrative, whereas line 2 opens the possibility of a quest narrative. The patient may respond similarly to either question but there is a risk of missing valuable new information in scenario 1 since this line may be read by the patient as meaning that you only want to know about the headache and are not interested in any additional symptoms that may have arisen between this visit and the last. In scenario 2, you will get on to asking specifically about the headache if the patient has not already mentioned it but you give an opportunity for additional stories to be told first. It can easily be seen from this example that the practitioner partakes in the construction of the patient’s narrative – somewhere along a spectrum from extensively so to minimally so . The practitioner is not, therefore, merely a witness to an improvised performance on the theme of the patient’s autobiography (practitioner-as-audience) rather, she is an active participant in the creation of the story (practitioner-as-ghost-writer). The practitioner must be aware of her role, power and opportunities in influencing the formation of the patient’s narrative on the one hand but equally aware of her interpretation of it on the other. These two strands: narrative formation and narrative interpretation are the key strands of narrative-based medicine. The practitioner interprets the patient’s narrative with regard to a complex and fluctuating combination of her own reference points and influences, including her: • Personal fund of story models (which include experiences, education, clinical models, etc.) • Perception of the aims of the consultation and ethical and bureaucratic parameters/constraints • Personal predicament (energy level, mood, degree of thirst/hunger/satiety, environment, other concerns on her mind, etc.) So how and when should the interpretive exercise around the patient’s narrative be done? Elwyn and Gwyn (1999 ) commend the use of discourse analysis which they describe as: ‘the study of language in context … [which] has its roots in linguistics, sociology and psychology but … is really no more than the examination of the processes of naturally occurring talk’. This is a method of textual analysis which works with detailed transcripts of ‘talk’ that are written using notation to indicate pauses, breaths taken, intonations, coughs, etc. Some study is required in order to be able to write and read such transcripts, particularly with regard to learning the language of the symbols used for notation. Discourse analysis can reveal the signals that patient and practitioner give to each other, not only in the words spoken but by pausing, coughing, etc. Practitioner and patient can send signals that indicate their: • Confusion or insight • Wish to change the subject or go into more depth • Desire to emphasize or underplay a point • Wish to clarify or explain • Attempt to register that they have been misunderstood • Wish to make a request. We tend to think that we notice these things automatically but discourse analysis reveals how much we miss – especially at the subtler end of the spectrum. Working with discourse analysis then can be hugely valuable in enhancing appreciation of what is actually being said in the consultation, what is wanting to be said and what is not being said. This method takes place in connection with written texts and therefore happens after the fact of the consultation. Nevertheless, it can help develop skills that can then be applied during the consultation. This is vital since practitioners do not deal with written texts, they work with living people and the discourse analysis cannot wait until after the consultation if it is to be helpful to specific patients – it must occur while the consultation is happening. We therefore need to practise a form of discourse analysis in action so that, as the concept of reflective practice maintains, the practitioner can conduct reflection in practice (during the consultation) as well as reflection on practice (after the event). The practitioner’s task during the case history, then, is multilevelled and complex since it combines a number of overlapping or simultaneous foci that must be accounted for, comprising considerations given to: • Analysis of the discourse to do with the patient’s and the practitioner’s messages and meanings • Generation and consideration of differential diagnoses • Reflection on potential treatment options or modulations • The need for referral or additional strategies. Although it might be suggested that these four steps be taken sequentially, that only tends to happen at the student or novice practitioner level since one of the hallmarks and necessities of highly skilled practice is the ability to continuously access maps, models and options and to generate and test hypotheses. This is what happens during the case history – this is the heart of it. The key to successful practice in narrative-based medicine lies with the ability to retain primary focus on the patient and what is actually being said while (and not instead of) reflecting and hypothesizing. Having said this it should also be appreciated that there are crucial moments where the practitioner should give total attention to the patient, consciously suspending all other considerations (as far as that is ever possible). We tend to think of narratives as linear entities; after all, is it not so that all ‘good’ stories have a beginning, middle and an end? Patient narratives are not like this, as we observed in the previous chapter – patients generate multiple stories which overlap, intertwine, repeat, dissolve, mutate, conflict with each other, fizzle out, ‘go nowhere’ and are subject to continual revision. The method of construction of patient narratives is more reminiscent of William Burrough’s cut-up technique than that prevailing in the eighteenth century novel. The practitioner working with narrative needs to pick up on cues, make connections, check for meaning and scry for potentials but should be on guard against, and resist the urge, to form the patient’s narrative into a neatly comprehensible linear tale, let alone try to match and locate it within any single grand historical narrative. In reading about NBM, one gets the feeling that some authors see it as a new medical utopia. Let us guard against this impulse too. NBM, again, represents just one model that is there to be integrated with a multiplicity of others enabling an increased synergistic dynamic. Gray (2007 ) has warned of the dangers of constructing grand unifying narratives in a searing critique of current utopianism and millenarianism: The dominant western myths have been historical narratives, and it has become fashionable to view narrative as a basic human need. Humans are tellers of tales, we have come to think, who cannot be happy unless they can see the world as a story …

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• Research article
• Open access
• Published: 28 September 2015

Teaching history taking to medical students: a systematic review

• Katharina E. Keifenheim 1 ,
• Martin Teufel 1 ,
• Julianne Ip 2 ,
• Natalie Speiser 1 ,
• Elisabeth J. Leehr 1 ,
• Stephan Zipfel 1 , 3 &
• Anne Herrmann-Werner 1  

BMC Medical Education volume  15 , Article number:  159 ( 2015 ) Cite this article

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This paper is an up-to-date systematic review on educational interventions addressing history taking. The authors noted that despite the plethora of specialized training programs designed to enhance students‘ interviewing skills there had not been a review of the literature to assess the quality of each published method of teaching history taking in undergraduate medical education based on the evidence of the program’s efficacy.

The databases PubMed, PsycINFO, Google Scholar, opengrey, opendoar and SSRN were searched using key words related to medical education and history taking. Articles that described an educational intervention to improve medical students’ history-taking skills were selected and reviewed. Included studies had to evaluate learning progress. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI).

Seventy-eight full-text articles were identified and reviewed; of these, 23 studies met the final inclusion criteria. Three studies applied an instructional approach using scripts, lectures, demonstrations and an online course. Seventeen studies applied a more experiential approach by implementing small group workshops including role-play, interviews with patients and feedback. Three studies applied a creative approach. Two of these studies made use of improvisational theatre and one introduced a simulation using Lego® building blocks. Twenty-two studies reported an improvement in students’ history taking skills. Mean MERSQI score was 10.4 (range 6.5 to 14; SD = 2.65).

Conclusions

These findings suggest that several different educational interventions are effective in teaching history taking skills to medical students. Small group workshops including role-play and interviews with real patients, followed by feedback and discussion, are widespread and best investigated. Feedback using videotape review was also reported as particularly instructive. Students in the early preclinical state might profit from approaches helping them to focus on interview skills and not being distracted by thinking about differential diagnoses or clinical management. The heterogeneity of outcome data and the varied ways of assessment strongly suggest the need for further research as many studies did not meet basic methodological criteria. Randomized controlled trials using external assessment methods, standardized measurement tools and reporting long-term data are recommended to evaluate the efficacy of courses on history taking.

Peer Review reports

In the course of his or her professional life, a clinician will conduct between 100,000 and 200,000 patient interviews [ 1 , 2 ]. The medical interview is the most common task performed by physicians. Thus, for good reason, Engel and Morgan called it “the most powerful and sensitive and most versatile instrument available to the physician” [ 3 ]. Scientific discoveries and technological innovations of the last decades fundamentally changed diagnostics and treatment of diseases. Imaging studies and laboratory tests seem crucial for an accurate diagnosis, all the more in times of multidisciplinary treatments and overall availability of instrument-based examinations. But neither scientific nor technological advances in medicine have changed the fact that a physician’s core clinical skills are interpersonal [ 4 – 6 ]. Interview skills contribute significantly to problem detection, diagnostic accuracy, patient and physician satisfaction, patient adjustment to stress and illness, patient recall of information, patient adherence to therapy and patient health outcomes [ 7 – 11 ]. Accuracy of diagnoses and the establishment of a good physician-patient relationship depend on effective communication within the medical interview [ 12 , 13 ]. By the medical history, physicians garner 60–80 % of the information that is relevant for a diagnosis [ 13 – 17 ] and the history alone can lead to the final diagnosis in 76 % [ 13 ].

There are different definitions and models of history taking in the international literature, suggesting a limited shared understanding of the medical interview. Several statements and checklists try to define what qualifies a medical interview as “good” and come to divergent results. One reason might be that history taking is highly contextual, depending on situation, patient and physician attributes, cultural characteristics and other factors. For example, a “good” medical interview in an emergency ward would differ distinctly from a “good” first interview in a psychiatric medical practice. Several authors refer to the “three-function model” [ 18 ] that highlights gathering data (1), responding to patients’ emotions (2) and educating patients and influencing their behaviour (3) as main functions of the medical interview. Each function is served by a separate set of skills. Other models focus on risk assessment, collection of data to make a diagnosis and assessment of patients’ available support system [ 19 ] as main tasks within the medical interview. The “five step model” [ 20 ] links physicians’ patient-centred skills with a more focused proceeding within the interview. Other models emphasise patient-centeredness even more, describing an equal exchange of information and shared decision-making [ 21 , 22 ]. Despite this heterogeneity, there seems to be an agreement that in a “good” medical interview, patient-centered techniques must at least complement the traditional clinician-centred focused questioning style.

Being a successful communicator has long been seen as part of the “art” of medicine, implying that communication skills were a natural gift with which one was or was not born [ 23 ]. However, some researchers described that basic communication skills deteriorate during medical education if they are not particularly activated and practised [ 24 , 25 ]. Students’ psychosocial interviewing skills especially seem to decline without targeted interventions [ 7 , 19 , 25 ]. This has often been associated with students’ growing medical knowledge and concentration on clinical reasoning and diagnostic skills. On the other hand, many studies have shown that students, having passed specialized history taking skills training, ask relevant questions and structure their interviews well. They are better at responding appropriately to patients’ verbal and non-verbal cues [ 26 ] as well as being able to elicit greater quantity and quality of information [ 27 , 28 ].

History taking and communication skills programmes have become cornerstones in medical education over the past 30 years and are implemented in most US [ 6 ],Canadian [ 8 ], German [ 29 ] and UK [ 30 ] medical schools. National accreditations and expert panel consensus guidelines have stressed the importance of educational interventions addressing history taking [ 31 , 32 ]. Today, it is a proven fact that interview skills can be taught if effective methods are used. Even 25 years ago, articles and consensus statements outlined the assumed essential elements of effective interview skills courses [ 33 , 34 ], despite not having much experiential evidence for their recommendations. Since then, many studies investigated the effectiveness of a multitude of different educational methods for teaching history taking. But there is still an uncertainty about: which of these methods are particularly effective; when in the curriculum they should be implemented; or which method is especially helpful for certain subgroups, for example, male or female students or not being a native speaker. In view of this uncertainty, the present systematic review of the literature has been undertaken to collect the currently reported knowledge in the field of teaching history taking in order to make recommendations for curriculum planners, medical teachers and future investigators.

Review objectives

This review aims to answer the following questions: (1) What interventions to teach history taking to medical students exist? (2) How has the effectiveness of these interventions been measured? (3) What is the quality of evidence for these interventions?

Information sources and search

This review process was conducted according to the PRISMA statement [ 35 , 36 ]. The databases PubMed, PsycINFO and GoogleScholar were searched for articles published between January 1990 and June 2014. Hand searches were performed in the reference lists of the search results. Additionally, the “grey literature” databases opengrey, opendoar and SSRN were searched.

Search terms were related to history taking and medical education, using combinations of the following: medical history taking, history-taking, medical communication, medical interview, anamnesis, medical students, medical education and teaching . Search was narrowed to titles and abstracts and terms were searched as MeSH-Terms in PubMed. It was ensured that the search terms captured the previously published reviews [ 37 , 38 ] and all relevant studies included in these reviews.

Underlying definition of “history-taking”

The authors of this review understand “history-taking” as a way of eliciting relevant personal, psychosocial and symptom information from a patient with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medical interview is seen as an encounter between physician and patient, both contributing to the results.

Inclusion criteria

Articles were included if the following criteria were met:

Description of an educational intervention concerning history taking: This review investigates (introductory) workshops teaching history-taking in general, considering content, completeness, verbal and non-verbal interviewing techniques and rapport.

Evaluation of learning progress (at least a self-evaluation of students)

Reporting on undergraduate medical education (i.e. “medical students”)

Publication dates between January 1, 1990 and June 30, 2014

English- or German-language articles

We also included articles that described teaching units addressing other clinical skills (e.g. physical examination or clinical reasoning) in addition to history taking if intervention and outcomes concerning history taking were reported in detail and separately from the results regarding the other objectives.

Exclusion criteria

The following results were excluded in this review:

Teaching units concerning only specific aspects of the medical history (e.g. taking a sexual history or an occupational history). Specific aspects of the medical interview are usually taught later in medical education and after an introductory course in medical interviewing has taken place, which is why interventions with regard to these specific aspects were excluded in this review.

Teaching units addressing communication skills in general, patient-centred behaviour or empathy without regard to history taking

Articles describing only the assessment of interview skills without describing a teaching unit

Articles with no measured outcome at all, e.g. project descriptions with course evaluation only and without any assessment of learning progress

Article selection and data collection

The literature search yielded 1254 potential publications on teaching units addressing history taking for medical students (see flowchart in Fig.  1 for complete search and study selection strategy). Following an initial review for relevancy by title and abstract (KEK and NS) and removal of duplicate results, 78 studies were left for full-text review, of these, 23 studies finally met the inclusion criteria. Interrater reliability was excellent with к = 0.84. In case of differing judgement, EJL was consulted as independent evaluator.

Flow chart of the literature search and study selection process

Relevant data was extracted from the included articles using an a priori developed data extraction form composed for this review (KEK, NS). Data extraction fields included (1) authors and year of publication, (2) description of study design and (3) participants, (4) description of the educational intervention, (5) assessment techniques and measurement tools, (6) reported change in history taking ability and (7) MERSQI score. Discussion with EJL resolved differences in data extraction.

Quality assessment

Study quality was considered using the Medical Education Research Study Quality Instrument (MERSQI), a tool developed especially to assess educational studies [ 39 ]. The 10-item scale (possible range 5 to 18) surveys the following domains: study design, sampling, type of data, validity of the evaluation instrument, data analysis and outcomes. Patient or health care outcomes are assessed higher than students’ satisfaction, attitudes or opinions. The MERSQI domains are very similar to the required methodical standards that Sanson-Fisher suggested for educational studies [ 40 ]. Neither the authors of the MERSQI scale nor Sanson-Fisher and colleagues defined a cut-off value to differ methodically “good” studies from “less good studies”.

This systematic review includes 23 studies. Table  1 describes these studies in detail, reporting basic data concerning study design and participants, teaching methods and training procedures, assessment of learning progress, use of measurement tools and the calculated MERSQI score of the study (see Table  1 ).

Study characteristics

The study design of the 23 finally selected articles was heterogeneous. There were randomized, two-group, pre-post comparisons ( n  = 4) as well as randomized and non-randomized two-group post-tests ( n  = 6). Five studies were single-group pre-post comparisons and five were single-group post-test evaluations only. Two were modified cohort controlled studies and one a non-randomized, three-group post-test. Of those studies reporting the duration of their educational interventions, the shortest intervention took two hours and the longest took seven 4-hour sessions (28 h).

Outcome measures

Assessment methods and measurement tools, much like the study designs, also were very heterogeneous. In eight studies [ 9 , 10 , 24 , 26 , 28 , 41 – 43 ] out of 22, trained observers assessed an interaction between a student and a simulated patient (SP) using a standardized history taking measurement tool. Seven of the applied scales were specific to history taking, but only one had a proven reliability and validity and all of them had been developed especially to assess the published intervention. The remaining 15 studies used either non-validated, self-report questionnaires developed by the respective study investigators, course evaluation questionnaires or qualitative analyses of students’ comments. One of the studies used a written examination; one used focus groups. Twenty-two studies out of 23 found positive effects of their educational interventions on students’ history-taking skills. For a full overview of the results see Table  1 .

Study quality

The mean MERSQI score for the 23 included studies was 10.36 (SD 2.65) [ 39 ]. The range was from 6.5 to 14 (possible range 5 to 18). Scores were limited especially by: deficiencies in the field of study design (ex: no control group, missing baseline measurements or lack of randomization); by missing validity of the outcome measurement tools; and by measurement of students’ attitudes or skills rather than by patient or health care outcomes.

Interventions

Instructional (traditional) approaches, focus scripts.

Students in the multi-institutional RCT of Peltier [ 44 ] received “focused history and physical exam scripts” (Focus Scripts). The authors developed one generic acute patient script template and one template for a focused chronic illness history. The organizational structure of the scripts was aimed to support students’ collection of data on any symptom. Students’ written progress notes were scored by a blind rater using a standardized scale. Five of 11 variables were statistically higher in the group that learned with the focused scripts. These included history taking, clarity of diagnosis and overall score. This intervention focuses on content and completeness of the medical interview and does not take verbal or non-verbal interview skills into account.

Videotape review: Communication benchmarks

Losh [ 45 ] held a lecture introducing communication benchmarks for inpatient history and then showed short videotaped scenarios that illustrated segments of a student history, contrasting an acceptable version of communication with a better version. The better version demonstrated the appropriate benchmarked skills. The scenarios were used in teaching sessions to help students identify effective communication techniques within the medical interview. Participants were medical students doing their first medical interview. After the sessions, 76 % of the students felt that this design helped them to understand the introduced communication benchmarks and 92 % felt that the videotape helped to point out subtle communication issues that might otherwise have been missed. The intervention imparted both knowledge about content and structure of the medical interview and particular communication skills.

Online course

Wiecha [ 46 ] reported on an online course developed to teach the cognitive basis for interviewing skills. The authors provided video demonstrations of patient interviews, text modules presenting communication concepts (not further clarified by the authors) and a moderated, asynchronous discussion board asking students to post their observations. The authors addressed questioning techniques, affect and nonverbal cues, eliciting the cardinal features of a symptom, and stages and transitions. Students received individual feedback on their participation and performance by personal e-mail. They reported improvement in self-awareness, increased understanding of interviewing concepts and benefits of online learning. Self-reported knowledge scores also increased significantly.

Experiential (“learning by doing”) approaches

Small group workshops including role-play and feedback.

In two studies [ 28 , 41 ], students participated in small group workshops practising history taking by role-play. Feedback was provided by facilitator and group members. Evans [ 28 ] implemented a specialized history-taking training programme consisting of lectures and skills workshops. Trained students were significantly more efficient on all areas covered by the applied scale (commencement of the interview, problem processing, communication, summary and overall effectiveness). In a non-randomized, controlled study, Mukohara [ 41 ] implemented a 2-day seminar on communication process skills and content aspects of the medical interview. Learning activities were a trigger videotape critique followed by role-play with videotape review and feedback by facilitator and group. The authors found an improvement for students’ ability to assess “how the illness affects the patient’s life”. No differences were observed between intervention group and waiting control group in the other 15 core communication skills.

Small group workshops including simulated patients

Ten studies [ 7 , 24 , 28 , 42 , 43 , 47 – 52 ] reported on interventions using simulated patients (SP). SP interviews were conducted by one of the participating students and were usually combined with a feedback session and discussion. Feedback was given by the group and/or the facilitator. SP interviews in these workshops were often supplemented by lectures, demonstrations, small group exercises including role-play and self-reflection. Battles [ 47 ] used SPs with abnormal medical histories to demonstrate pathology. Utting [ 43 ] compared two skills courses using an active “learning by doing” approach with one course and applying instructional methods in the other. The authors found no differences in students’ interview skills, which were assessed using standardized scales. Eoaskoon [ 48 ] conducted a three-group post-test. SP interview and feedback (1) were compared with role-play and feedback in front of the group (2) and role-play and feedback within the group (3). The group that trained with SP interviews gained the highest scores with regard to interview skills. Five studies [ 24 , 42 , 49 – 51 ] used videotape review for feedback. Kraan [ 24 ] investigated a graded teaching program of medical interviewing skills. Each year a different set of skills was highlighted. In the first years, basic interviewing skills, medical history-taking skills and psychosocial issues were emphasized. Effective exchange of information and difficult situations such as dealing with aggressive patients or sexual problems were topics for advanced learners. Each small group had both a physician and a behavioural scientist as facilitators. Ozcakar [ 42 ] found that students having both verbal and visual (videotape review) feedback were more successful than those having verbal feedback alone. Although self-assessment of the students did not improve significantly, feedback based on videotaped interviews was superior to the feedback given solely based on the observation of assessors. Hulsman [ 49 ] showed that students valued SP interviews, video observation and feedback as instructive and helpful to develop their own strengths and to identify certain kinds of behaviour to improve. Nestel and Kidd [ 50 ] used peer tutors and reported no differences regarding patient-centred interview skills between groups taught by peers and those taught by faculty. Von Lengerke [ 51 ] and Fortin [ 7 ] found that SP interviews were evaluated as one of the most effective teaching methods. Von Lengerke performed a pre-post comparison of students’ self-assessed competencies and had participants evaluate key teaching methods. In addition to history taking, disclosure of diagnosis was taught in this course. Fortin [ 7 ] focused on integrating patient-centred skills (listening, negotiating, responding to emotion empathetically, focusing the patient’s story) into a medical interview skills course. Mini-lectures, demonstrations by faculty and role-play preceded the SP interviews.

Using virtual patients

One RCT by Vash [ 53 ] reported on small groups working on virtual surgical patients in a computer lab. The patient was initially introduced to them, and then the students worked through eight sections including interview (chief complaint), medical history and review of systems. Students had to ask relevant questions by typing them. Students in the lab performed better than their colleagues in the control group, which had seen patients in the surgery clinic instead. Significant differences were only found in the history taking area.

Small group workshops including real patients

Four interventions [ 9 , 10 , 26 , 54 ] provided real patients. Fischer [ 54 ] included real patient interviews at the end of a course including role-play and simulated patients as well. Students interviewed real patients and videotaped the interviews. One aspect of the intervention was that the students visited the real patients in their homes. The interviews were watched back in the classroom and the students received feedback from facilitators and group members. The authors reported a significant learning progress and improvement in taking a case history. Results of self-reported questionnaires corresponded well with the results of the Objective Structured Clinical Examination (OSCE). Windish [ 10 ] compared a communication skills course applying SPs to a control group interviewing inpatients. Students in the intervention group were better at establishing rapport and were able to list more psychosocial history items. Evans [ 26 ] used real patients in the context of a communication skills course. The authors applied lectures, role-play, SP interviews and discussion as well. All three studies made use of videotape review. Novack [ 9 ] included interviews with real patients in a course using lectures, role-play and discussion as well as textbooks with additional information. Students were supposed to follow a chronically ill patient for 1 year and after regular interviews, write up progress notes.

Creative approaches

Improvisational theatre.

Watson [ 55 ], as well as Shochet [ 56 ], implemented elective courses including improvisational theatre techniques to improve specific communication skills. In Shochet’s study, students practised specific skills including listening, affirmation, non-verbal communication and other skills. Students discussed the relevance of these skills in communication with their patients. The authors showed that students felt more confident in their role as future physicians after the course and that they improved their ability to be flexible in communication styles and “respond in the moment”. Most students thought that the concepts that were addressed in the course were highly relevant to the care of patients. Students in Watson’s classes felt they became better listeners and observers.

Lego® simulation

Harding and D’Eon [ 57 ] implemented a Lego® simulation in their interactive lecture to improve patient-centred interviewing skills. Student volunteers took on the roles of doctor and patient. The doctor had to query the patient and through his responses replicate the patient’s Lego® construction without looking at it. The authors found this intervention helped preclinical students to concentrate on interviewing skills without being preoccupied with medical knowledge.

Heterogeneity of interventions

One clear finding of the literature review is that the included studies applied very heterogeneous teaching methods and determined different core areas to teach. While some interventions focused on content or structure of the medical interview and imparted techniques on “how to ask the right questions”, others highlighted non-verbal communication skills, patient-centeredness and establishing rapport. There is no accordance on when in medical education certain skills should be taught, leading to interventions that were taught for students at very different levels of training. While some studies evaluated long existing training programmes extending over several semesters, others investigated innovative approaches sometimes lasting only a few hours.

Fourteen studies included medical students in the preclinical years, eight studies included students in the clinical years and one study included both. Authors of the studies investigating improvisational theatre and Lego® simulation presumed that preclinical students might especially benefit from creative approaches where no significant medical knowledge was required. Not being preoccupied with complicated clinical reasoning may facilitate history-taking exercises for this subgroup and enhance patient-centred approaches.

Heterogeneity might also be due to the context dependence of the medical interview itself. Goals of the included studies were to enable students to attain a set of basic knowledge and skills in the medical interview. But encounters with patients are highly complex events and no simple approach can do justice to all possible processes and challenges in such interactions. No single course can comprehensively address all the communication problems that a physician will encounter, nor will skills be effective in every imaginable clinical situation.

Most articles in the field of history taking don’t differentiate between interview skills, interpersonal skills and communication skills – this conceptual mixture also contributed to the heterogeneity of interventions. Very often, specific interpersonal and communication skills (e.g. nonverbal behaviour, communication of empathy) are taught within the context of medical interview courses. Maybe an exact separation of these terms and definitions is neither even possible nor desirable as there is a continuum from communication skills to interview skills to history taking.

Assessment of history taking skills

Six different methods of assessing learning progress were applied in the included studies. Many studies used more than one of the following:

Self-evaluation questionnaires

Free-text response on what students learned from the workshop

Written examinations

Qualitative analysis of students’ reflections and write-ups

Assessment of (videotaped) interviews by either trained observers, SPs or student tutors, either using a checklist/validated measurement tool or just giving a global impression

OSCE-stations and assessment of the interviews by trained observers or SPs, using a checklist/validated measurement tool.

Studies with a higher MERSQI score (>11.5) mostly used the latter methods (numbers 4, 5, 6) of assessing learners’ progress. Very often, they combined different methods and had self-report course evaluation forms as well as formal assessments of students’ interviews with SPs.

Findings from the MERSQI score

If articles are sub-divided by methodological quality, it becomes apparent that studies with a higher MERSQI score (>11,5) often report on small-group skills workshops using role-play, simulated patients, virtual patients and/or real patients. In these courses, teachers and group, sometimes also SPs or peer tutors, give feedback. Mostly, interviews are videotaped to facilitate and enhance feedback. Studies with a lower MERSQI score (<9) frequently apply a more traditional approach using demonstrations, theoretical sessions and self-study. As creative approaches also tend to achieve a lower MERSQI score, innovative approaches don’t seem to be associated with a better study quality. Experiential approaches (“learning by doing”, see Table  1 ) achieved the highest MERSQI scores. Differences in MERSQI scores are primarily explicable by implementation of control groups, objective assessment of (videotaped) interviews and use of assessment tools. Limitations of the MERSQI score could be that the scale is based on a quantitative experimental study design paradigm that might underestimate qualitative or observational studies. Reliance on the MERSQI score only might therefore be biased towards particular forms of research.

Implications for future research

With regard to content, the included interventions were often innovative, mostly well-thought-out and substantiated. Many of them were descriptive studies that relied on students’ self-evaluation and didn’t provide evidence that the intervention was effective in improving history-taking skills. Though there is a well-established methodology for adequate evaluative research that should be used if the effectiveness of history-taking courses is to be properly determined, studies mostly lack baseline measurement, randomization, adequate control groups, external measurement, blinded raters or standardized measurement scales. Often self-developed assessment scales were used although proven scales for external assessment do exist (for example the History-Taking Rating Scale (HTRS) [ 28 ], the Maastricht History-taking and Advice Checklist (MAAS) [ 24 ] or the Brown Interviewing Checklist (BIC) [ 6 ]). And although essential elements of effective history taking courses were defined in the 80s and 90s [ 33 , 34 ], there is still no evidence-based gold standard that could serve as control group for an innovative new approach. Of course innovative ideas should be described in articles to provoke and stimulate discussion with colleagues but there is still a need for substantiated not just experiential studies. Innovative new concepts must be welcomed, but they should be coupled with acceptable methodology to examine and demonstrate their effectiveness [ 40 ].

An effort should always be made to question if certain interventions provide a more significant improvement for certain groups of students. There may be circumstances that predispose students to require more specific interventions, for example a non-native speaker of a language may need training in appropriate phrasing of questions as well as non-verbal cues to be most effective at history taking.

Implications for curriculum planners and medical teachers

Small group workshops including interview simulations (role-play, SP interviews, virtual patients) and interviews with real patients, followed by feedback and discussion, are widespread and have been most thoroughly investigated and reported on. Feedback using videotape review seems to be particularly successful in providing students with instructive techniques in history taking. Students in the early preclinical state might profit from creative approaches helping them to focus on the interview skills and not being preoccupied by attempts to make diagnoses beyond their abilities. There is no evidence on when history-taking workshops should take place in the curriculum. Some authors recommend implementing them in the clinical clerkships, others favour implementation in preclinical years. Curriculum planners should consider addressing the reported decline in history-taking skills over time when medical interviewing is taught early in the curriculum, especially concerning psychosocial issues. This might be achieved by implementing a long-term “communication skills” course or by offering booster sessions later in the clinical years.

Limitations of this review

It is possible that our search strategy may have missed some papers, especially those published in different languages as we only included articles written in English or German. However, it is unlikely that we missed a substantial number of relevant publications, especially as this review covers such a long period. But more important than that, this review only included published studies while it is recognized that many training programs do teach history taking in a variety of ways world wide that may not be mentioned in this review as they have not been published.

History taking is an essential skill of every physician and has to be taught in the course of their medical education. Today, there are many studies demonstrating that students can acquire interview skills by specific workshops. There seems to be little evidence noting the superiority of one specific method however, there is a broad scope of interventions that all seem to provide history taking skills. It is not known if the acquired skills can be generalized across situations or maintained over time.

Important formal goals for this research area are to meet acceptable methodological standards for evaluative research. External measurement of students’ skills – either by a clinician, a SP or student/peer tutor utilizing established proven scales – is an important objective for the evaluation of future methods of teaching history taking. Practical examinations involving SPs, especially OSCE stations, should be gold standard in assessing history taking skills.

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Katharina E. Keifenheim, Martin Teufel, Natalie Speiser, Elisabeth J. Leehr, Stephan Zipfel & Anne Herrmann-Werner

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Keifenheim, K.E., Teufel, M., Ip, J. et al. Teaching history taking to medical students: a systematic review. BMC Med Educ 15 , 159 (2015). https://doi.org/10.1186/s12909-015-0443-x

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• Undergraduate medical education
• Medical students
• History taking
• Medical history
• Medical interview
• Interview skills

BMC Medical Education

ISSN: 1472-6920

• Submission enquiries: [email protected]
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The importance of thorough history taking

• December 3, 2019
• Thyroid disorders
• By Kate Davies

Case history

A 4-year-old girl, referred to the Paediatric Assessment Unit by the GP, with a 2-week history of a cough, feeling unwell, and tired. Accompanied by her mother.

Read the patient information below and answer  Question 1.

Early history

• Born at term in the UK
• Family are from Bangladesh

Health and medication history

• Coughing a lot – nothing is helping
• Feeling tired
• Not vomiting when coughing, no haematemesis
• Not eating or drinking well
• No concerns with bowels or passing urine

School history

• No medical history, never been in hospital
• Not on any prescribed medication
• Using over-the-counter cough mixture, although it has not helped
• No herbal medication, no medication sourced from the internet, no access to recreational drugs
• Immunisations up to date – including BCG (offered in the UK in high-risk areas)
• Had chickenpox last year
• Family live in East London, known as a high-risk area with increased prevalence of tuberculosis
• No recent foreign travel, although paternal uncle has just returned from Bangladesh

Family history

• Reception year at primary school
• Has lots of friends
• Mother has type 2 diabetes
• Maternal grandmother has an underactive thyroid
• Mother is 153 cm
• Father is 169 cm

On examination

• Her ears, nose and throat are clear, but she is clammy and sweaty.
• There is no increased work of breathing, with good air entry, but there is a slight wheeze bilaterally and she has swollen cervical lymph nodes.
• She has no dysmorphic features, no goitre and is cardiovascularly stable but is tachycardic.
• She is tall for her age in comparison to her parents.

Concluding the history

Mother concerned about the cough.

Thinks she has a cold.

On asking if there was anything else, mother feels she may have been a bit more sweaty in the last few weeks, but was not concerned.

Question 1.

What would your differential diagnoses be?

• Endocarditis
• Hyperhidrosis
• Upper respiratory tract infection
• Phaeochromocytoma
• Tuberculosis

Hyperthyroidism

Question 2.

Which clinical signs or symptoms are making you suspicious?

• History of cough
• Tall stature
• Tachycardia
• Family foreign travel
• Geographical area
• Doing well at school
• Family history of thyroid disease
• Tuberculosis risk
• Family recent foreign travel
• Chickenpox history

Question 3.

Which laboratory tests and investigations do you are think are needed to reach your definitive diagnosis?

• Sputum sample
• Naso-pharyngeal aspirate
• Lung spirometry
• Stool sample
• Urine sample
• Blood cultures
• Chest X-ray
• ECG (electrocardiogram)
• Full blood count (FBC)
• C-reactive protein (CRP)
• Urea &amp; electrolytes (U&amp;E)
• Liver function tests (LFT)
• ESR (erythrocyte sedimentation rate)
• 24 hr urine collection for catecholamines
• Thyroid function tests
• Thyroid ultrasound
• Mantoux test

Chest X-ray. ECG (electrocardiogram). Full blood count (FBC). C-reactive protein (CRP). Urea & electrolytes (U&E). Liver function tests (LFT). ESR (erythrocyte sedimentation rate). 24 hr urine collection for catecholamines. Thyroid function tests. Thyroid ultrasound. Mantoux test

Further endocrine investigations

Question 4..

Which diagnoses are confirmed or refuted?

Question 5.

Which further blood test could be performed to further refine the diagnosis?

• Thyrotrophin-releasing hormone (TRH) test
• Combined insulin tolerance/TRH/gonadotrophin-releasing hormone test

Thyroid-stimulating hormone (TSH) receptor antibodies

TSH receptor antibodies 0.84 miU/L (normal range 0.0–0.4)

Consistent with Graves’ disease

Management and follow-up

Referral made to the paediatric endocrinology services for management

Question 6.

What is your management plan and in what order would you do this?

• Commence antithyroid drug, carbimazole
• Refer to nurse-led paediatric endocrine clinic
• Refer for radioactive Iodine therapy
• Refer to surgical team for thyroidectomy

How can raised levels of TSH receptor antibodies manifest clinically? What else do increased thyroid hormones do?

Shared care was planned with the patient’s GP, for them to repeat prescriptions of carbimazole, 5 mg once daily. A further outpatient appointment was offered for 2 weeks’ time with repeat thyroid function test. Parental understanding needed to be ensured, so a referral was made to the nurse-led thyroid clinic for further education and support.

No treatment was needed for the cough, which self-resolved.

This case shows that thyroid symptoms can be subtle and easily missed. It underlines the importance of detailed history-taking and clinical examination, and shows that sometimes the presenting complaint can be misleading.

• Atkinson P, Taylor H, Sharland M & Maguire H (2002): Resurgence of paediatric tuberculosis in London  Archives of Diseases in Childhood  86, 264 – 265.
• Bellet JS (2010): Diagnosis and treatment of primary focal hyperhidrosis in children and adolescents.  Semin Cutan Med Surg  29, 121-126.
• Benson RA, Palin R, Holt PJ & Loftus IM (2013): Diagnosis and management of hyperhidrosis.  BMJ  347, f6800.
• Cheetham T, Hughes IA & Barnes ND (1998): Treatment of hyperthyroidism in young people.  Arch Dis Child  78, 207 – 209.
• Dixon G & Christov G (2017): Infective endocarditis in children: an update.  Curr Opin Infect Dis  30, 257-267.
• Esposito S, Tagliabue C & Bosis S (2013): Tuberculosis in Children  Mediterranean Journal of Hematology and Infectious Diseases  5, 1 – 8.
• Havekes B, Romijn JA, Eisenhofer G, Adams K & Pacak K (2009): Update on pediatric pheochromocytoma.  Pediatr Nephrol  24, 943-950.
• Johnston, Chew, Trainer, Reznek, Grossman, Besser, Monson & Savage (2000): Screening children at risk of developing inherited endocrine neoplasia syndromes.  Clinical Endocrinology  52, 127-136.
• Kirsten D (2000): The thryoid gland: physiology and pathophysiology.  Neonatal Network  19, 11 – 26.
• Leger J & Carel JC (2013): Hyperthyroidism in childhood: causes, when and how to treat.  J Clin Res Pediatr Endocrinol  5 Suppl 1, 50-56.
• Leger J, Kaguelidou F, Alberti C & Carel JC (2014): Graves’ disease in children.  Best Pract Res Clin Endocrinol Metab  28, 233-243.
• Minamitani K, Sato H, Ohye H, Harada S & Arisaka O (2016): Guidelines for the treatment of childhood-onset Graves’ disease in Japan.  Clin Pediatr Endocrinol  26, 26 – 62.
• NHS (2016) Tuberculosis: Factsheet (Health Do ed.). NHS, London.
• NHS (2018) The National Child Measurement Programme. NHS. Available at:  https://www.nhs.uk/Livewell/childhealth1-5/Pages/ChildMeasurement.aspx .
• Pimentel J, Chambers M, Shahid M, Chawla R & Kapadia C (2016): Comorbidities of Thyroid Disease in Children.  Adv Pediatr  63, 211-226.
• Priesemann M, Davies KM, Perry LA, Drake WM, Chew SL, Monson JP, Savage MO & Johnston LB (2006): Benefits of screening in von Hippel-Lindau disease–comparison of morbidity associated with initial tumours in affected parents and children.  Horm Res  66, 1-5.
• Raine JE, Donaldson MDC, Gregory JW & van Vliet G (2011) Practical endocrinology and diabetes in children, 3rd edn. Wiley – Blackwell, Chichester.
• RCPCH/WHO (2016) Growth Charts 0 – 18 years. RCPCH. Available at:  https://www.rcpch.ac.uk/growthcharts  (accessed 7 January 2018 2018).
• Ruwende JE, Sanchez-Padilla E, Maguire H, Carless J, Mandal S & Shingadia D (2011): Recent trends in tuberculosis in children in London.  J Public Health (Oxf)  33, 175-181.
• Schenk D, Donaldson M & Cheetham T (2012): Which antithyroid drug regimen in paediatric Graves’ disease?  Clin Endocrinol (Oxf)  77, 806-807.
• Schlereth T, Dieterich M & Birklein F (2009): Hyperhidrosis–causes and treatment of enhanced sweating.  Dtsch Arztebl Int  106, 32-37.
• Waguespack SG, Rich T, Grubbs E, Ying AK, Perrier ND, Ayala-Ramirez M & Jimenez C (2010): A current review of the etiology, diagnosis, and treatment of pediatric pheochromocytoma and paraganglioma.  J Clin Endocrinol Metab  95, 2023-2037.
• Williams JL, Paul D & Bisset G, 3rd (2013): Thyroid disease in children: part 2 : State-of-the-art imaging in pediatric hyperthyroidism.  Pediatr Radiol  43, 1254-1264.

Meet the author

Kate davies.

Children’s Nursing, UK

• Adrenal disorders
• Bone disorders
• Obesity/Type 2 diabetes
• Pituitary/growth disorders
• Puberty disorders
• Type 1 diabetes

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Learning to Diagnose with Simulations pp 109–122 Cite as

Live and Video Simulations of Medical History-Taking: Theoretical Background, Design, Development, and Validation of a Learning Environment

• Maximilian C. Fink 3 ,
• Victoria Reitmeier 3 ,
• Matthias Siebeck 3 ,
• Frank Fischer 4 &
• Martin R. Fischer 3  
• Open Access
• First Online: 11 February 2022

3542 Accesses

1 Citations

History-taking is an essential diagnostic situation and has long been an important objective of medical education in European countries and beyond. Thus, the research project presented here investigates facilitating diagnostic competences in live and video history-taking simulations. In this chapter, the theoretical background and the design, development, and validation process of the learning environment for this research project are described. In the first section, an overview of history-taking models is provided, the concept of diagnostic competences for history-taking is specified, and a summary of research on simulation-based learning and assessment of history-taking is given. The second section reports on the creation of knowledge tests and the live and video simulations. In the third section, results from a pilot study and an expert workshop are disclosed and findings from a validation study are provided. These findings indicate that the created simulations and knowledge tests measure separate but related aspects of diagnostic competences reliably and validly and may be used for assessment. In the final section, a summary is provided and future questions for research are presented with a focus on the adaptivity of scaffolds and simulation-based learning from atypical cases.

You have full access to this open access chapter,  Download chapter PDF

This chapter’s simulation at a glance

9.1 Introduction

History-taking is an essential diagnostic situation for physicians for two reasons. According to a recent literature review, 60–80% of relevant information in medical diagnosing emerges from history-taking (Keifenheim et al., 2015 ). Moreover, about two-thirds of all medical diagnoses can be made accurately after taking a patient’s history (Peterson et al., 1992 ). Even though history-taking is of such great importance, intermediate students still experience difficulties in conducting comprehensive medical interviews for the purpose of diagnosing (Bachmann et al., 2017 ). Meta-analytic findings indicate that simulation-based learning conveys diagnostic competences effectively if adequate instructional support is offered to learners (Cook et al., 2010 , 2013 ). Instructional support measures such as reflection phases and role-taking seem promising for fostering diagnostic competences in history-taking situations because they are beneficial for acquiring complex skills in other contexts within medical training (Stegmann et al., 2012 ; Mamede et al., 2008 ). Presently, however, only limited empirical findings are available concerning facilitating diagnostic competences in history-taking simulations via these two instructional support measures (Keifenheim et al., 2015 ). Thus, this project aimed firstly to develop realistic history-taking simulations for the assessment of diagnostic competences. In a second step, this project will use these simulations in future studies that vary reflection phases and role-taking. Dyspnea (shortness of breath) was chosen as the key symptom of the cases in the simulations.

9.2 Theoretical Background

9.2.1 definition and models of the medical interview.

The medical interview is a dynamic encounter in which a physician and a patient interactively construct the patient’s medical history together (Haidet & Paterniti, 2003 ). This process is called history-taking. History-taking can be supported with assistive resources (e.g., history-taking forms), and takes place in all medical specialties with direct patient contact in diverse care contexts, including emergency medicine, family medicine and psychiatry (Keifenheim et al., 2015 ). According to popular models of history-taking (Bird & Cohen-Cole, 1990 ; Smith et al., 2000 ; Rosenberg et al., 1997 ; Kurtz et al., 2003 ), the medical interview can be conceptualized on a continuum from patient-centered to physician-centered. In patient-centered medical interviews, the patient’s psychological and social context is explored more extensively and the patient steers parts of the conversation (Henderson et al., 2012 ). In physician-centered interviews, by contrast, the patient’s physical symptoms are in focus and the physician leads the conversation. The medical interview can perform a wide range of communicative functions, including gathering data and making diagnoses, educating and making decisions, and establishing rapport (Roter & Hall, 1987 ; Jefferson et al., 2013 ). Depending on the specific context of a medical interview (e.g., an emergency room vs. a routine checkup), a patient-centered or physician-centered approach with the aforementioned communicative functions might be more relevant (Keifenheim et al., 2015 ). As this project applies an experimental paradigm and focusses on the simulation-based assessment and training of diagnostic competences in emergency room dyspnea cases, a physician-centered approach emphasizing the functions of gathering data and making diagnoses seems most suitable.

9.2.2 Diagnostic Competences in the Medical Interview

Diagnostic competences have been described on an abstract level using the framework presented in Chap. 2 (Chernikova et al., 2022 ) and will be specified here in the context of this project.

In all diagnostic settings, diagnostic quality is comprised of diagnostic accuracy and diagnostic efficiency. Diagnostic accuracy generally depends on the correctness of the diagnosis as well as its justification—reasoning for and against the main diagnosis. As it is often not possible to rule out all differential diagnoses in a medical interview without further examinations (Petrusa, 2002 ), the diagnosis and associated justification may be considered preliminary. Efficiency in history-taking is based not only on time spent, but also on the amount of relevant data gathered in this time and the cost and adverse effects of the examinations and interventions ordered.

The diagnostic process can be operationalized in this context primarily via the diagnostic activities of generating hypotheses, generating and evaluating evidence and drawing conclusions. Hypotheses are frequently formed at the beginning of the medical interview using the patient’s background information and initial complaint and are updated over the course of the interview (Pelaccia et al., 2014 ). Evidence generation takes place in history-taking primarily through asking questions but also includes interpreting visible signs (e.g., paleness as a symptom for pulmonary embolism) and acquiring necessary background information. In the medical interview, evidence evaluation is the analysis of the evidence contained in the background information, the signs and symptoms and the patients’ answers. The validity and reliability of the different pieces of evidence can differ significantly and must be determined on a case-by-case basis (Redelmeier et al., 2001 ). In history-taking, the reliability and validity of evidence can be particularly threatened when information is sensitive or difficult for patients to remember and comprehend. For instance, some patients with extensive medical knowledge present a meticulous documentation of the medication they have taken in the last year in the medical interview, while other patients with low medical knowledge experience difficulties remembering important medication they are currently taking. Drawing conclusions involves weighing the generated and evaluated evidence to make a decision. The result is the creation of a diagnosis and a justification.

According to the theoretical framework presented by this research group, individual prerequisites predict the diagnostic quality and diagnostic process . In the context of the medical interview, the professional knowledge base is a key component of these individual prerequisites (Stark et al., 2011 ; Förtsch et al., 2018 ) and can be differentiated into conceptual and strategic knowledge (Schmidmaier et al., 2013 ; Kopp et al., 2008 ). Conceptual knowledge is defined as “knowledge about the declarative textbook facts” (Schmidmaier et al., 2013 , p. 2), while strategic knowledge “comprises knowledge about problem-solving strategies and heuristics in the process” (Schmidmaier et al., 2013 , p. 2). Both types of knowledge, which form the professional knowledge base relevant for the simulation we present in this chapter, include content on diseases that may cause dyspnea as well as content related to conducting the medical interview.

9.2.3 Simulation-Based Learning and Assessment of History-Taking

We propose that history-taking can be facilitated and assessed with live simulations, video simulations and role-plays. Live simulations employ standardized patients who have been systematically trained to act as patients and display symptoms of diseases authentically (May et al., 2009 ). Video simulations include interactive videos of patients displaying symptoms. User input can take place through a menu or through free text input that is analyzed automatically, e.g., with natural language processing methods (Cook et al., 2010 ). In role-plays, students receive a script and play the roles of a physician, patient, and observer according to the script (Joyner & Young, 2006 ). Each of these simulation modalities has certain advantages and disadvantages in medical training. While live simulations are highly interactive, they require a great deal of administrative effort and produce ongoing high costs. Video simulations are expensive at the time of construction but can then be used indefinitely in digital learning environments without new expenditure. Role-plays are inexpensive but require participants to prepare well before taking part.

As seen in Chap. 2 (Chernikova et al., 2022 ), theoretical arguments and empirical evidence indicate that simulation-based learning with instructional support is a promising method for facilitating diagnostic competences. With regard to simulation-based learning in history-taking situations, 17 studies had been conducted by the time an extensive literature review appeared in 2015 (Keifenheim et al., 2015 ). Even though most of these studies reported positive effects of educational interventions, the literature review had limitations. Many of the included studies combined numerous educational interventions (e.g., lectures and small group work), focused on communication skills as an output measure or did not include a performance measure of diagnostic competences in the posttest. Specific results for reflection phases and roles are still not available for this context.

Live simulations have been used to assess performance in medicine for decades (e.g., Harden & Gleeson, 1979 ), and computer-based simulations have become increasingly popular (Ryall et al., 2016 ). The literature agrees that simulation-based assessment can be reliable and predict clinical performance (Ryall et al., 2016 ; Petrusa, 2002 ; Edelstein et al., 2000 ). However, the reliability and validity of the assessment depend on factors such as the authenticity and standardization of the simulated situation and patient, the choice of scoring algorithms and determination of expert solutions, and the sampling and number of cases (Petrusa, 2002 ; Weller et al., 2005 ; Clauser & Schuwirth, 2002 ). In general, it is recommended to use multiple, authentic and well-operationalized cases for assessment and to complement simulation-based assessment with other measures such as knowledge tests (Ryall et al., 2016 ).

9.2.4 Design, Development and Validation Process Objectives and Research Questions

The project focused in this phase on the creation and validation of live simulations and video simulations as assessment instruments. The main research questions were: Are live and video simulations valid and reliable assessment tools? [RQ 1], Are live and video simulations experienced as authentic? [RQ 2], and Are conceptual and strategic knowledge tests predictive of diagnostic quality? [RQ 3].

9.2.5 Simulation Design and Development

The project team consisted of two professors of medicine with expertise in medical education , one professor of educational psychology, a licensed physician and a Ph.D. student in learning sciences. The physician was mainly responsible for creating the content of the simulations and knowledge tests. The Ph.D. student primarily had the task of designing and conducting the experimental study. The professors acquired funding, supervised the physician and the Ph.D. student and offered feedback and advice on their academic work.

In a first step, dyspnea, the subjective feeling of shortness of breath, was selected as a cardinal symptom because it is one of the most common presentations in emergency rooms and GP practices (Berliner et al., 2016 ). A blueprint was drafted that specified the diagnoses of three training and six assessment cases. Two of the training cases focused on cardiac insufficiency and pulmonary embolism, while for one training case the diagnosis was COPD. Four of the six assessment cases involved specific types of cardiac insufficiency and pulmonary embolism (near transfer), while for two cases the diagnoses were hyperventilation and pneumonia, which are not similar to any training case (far transfer). Next, a case scenario was created to determine the structure and sequence of all cases. All cases would start with key prior information (such as a pathological laboratory test result or an ECG) and a presentation of the chief complaint by the patient. Then, the cases would proceed and be followed by 8 min of history-taking during which the participant could ask or select questions independently. In this phase, participants would mainly conduct a physician-centered interview, asking or selecting general screening questions (e.g., “Is this the first time you are encountering this problem?”) and specific questions to test certain diagnoses (e.g., “Have you had swollen legs?”). The questions covered the history-taking categories of principal symptoms, past medical history, allergies and current medication, social and family history and system overview and were based on a classification by Bornemann ( 2016 ). Then, students would provide a diagnosis and a justification in a case summary. Figure 9.1 depicts the simulation scenario, including the length of its elements and relevant processes (for more information, see the next section).

Simulation scenario

Developing a foundation for the live and video simulations, the licensed physician first created a set of history-taking questions as well as nine case vignettes. To create video simulations, a computer scientist programmed a video simulator with a menu and integrated it into the e-learning platform CASUS 3.0 (Instruct, 2018 ). Professional actors were filmed acting out the cases as standardized patients in a clinical setting and the videos were cut and embedded in the simulator. To produce live simulations, an experimental protocol was created that outlined the behavior of standardized patients and experimenters. The actors were trained to act out the case in face-to-face encounters and individual coaching was offered by the licensed physician. The simulations were conducted in a simulation center at the University Hospital of LMU Munich in Germany that offered three test rooms with a stretcher for the live simulations as well as a computer room for the video simulations and pretest. The final live simulation is displayed in Fig. 9.2 and the final video simulation in Fig. 9.3 .

Live Simulation of History-taking

Video Simulation of History-taking

9.2.6 Test Design and Development

To measure diagnostic competences according to the framework described in Chap. 2 , separate measures for diagnostic quality, the diagnostic process and the professional knowledge base were created.

Diagnostic quality was assessed with a case summary after each case. Participants listed the final diagnosis in the case summary and provided a justification for this diagnosis. Moreover, participants listed further examinations and treatments. The final diagnosis was chosen from a long menu (i.e., an auto-complete search list that contained many possible diagnoses) and the justifications, examinations and treatments were entered in a text field. Diagnostic accuracy was calculated by adding up partial scores for the final diagnosis (incorrect vs. partially correct vs. correct). The justification for the diagnosis was determined by the percentage of correct reasons mentioned out of all correct reasons for a case defined in the expert solution. Both of these facets of diagnostic accuracy were coded based on the learners’ answers by two physicians with a scoring rubric.

Diagnostic processes were tracked in video simulations with log files and in live simulations with video recordings. Video simulation data was coded automatically using R scripts. Live simulation data was coded by trained student assistants with a scoring rubric. In both types of simulations, tracked behaviors and their timestamps facilitated detailed analyses of the diagnostic activities. For instance, we investigated evidence generation in depth by analyzing the number and relevance of questions selected.

To measure the professional knowledge base, a conceptual and strategic knowledge test was created. These knowledge tests were based on the conceptualizations of professional knowledge by Förtsch et al. ( 2018 ) and Fischer et al. ( 2005 ). The conceptual knowledge test contained 39 questions and covered symptoms, etiology, therapy and further diagnostics and interventions for dyspnea. The questions used were extracted from a professional database for examinations. This knowledge test encompassed multiple-choice questions with a varying number of correct answers. The strategic knowledge test consisted of 10 key feature cases (i.e., short case vignettes that contain crucial clinical problems, see Hrynchak et al., 2014 ) on the topic of dyspnea that were developed by the physician as part of the project. Each case vignette contained four questions on the diagnosis, history-taking, treatment and further diagnosis.

9.2.7 Cooperation with Other Projects

The materials presented above were developed in collaboration with another project on facilitating cooperative medical diagnosing competences (Radkowitsch et al., 2022 ). Both projects developed comparable simulation blueprints and used the same case summary. The strategic and conceptual knowledge tests were structured in a similar way. Close collaboration also took place with yet another project on diagnostic competences in the diagnostic interview in mathematics education (Marczynski et al., 2022 ). This collaboration was mainly related to creating the live simulation. In both projects, similar blueprints were created before writing the case vignettes. Standardized patients and students were trained comparably. Measures of diagnostic accuracy and diagnostic processes were operationalized in a similar way in both projects.

9.2.8 Validation Process

A pilot study, an expert workshop and a validation study were conducted to evaluate topics such as the usability, authenticity and correctness of the simulations and tests and to make revisions.

A sample of N  = 12 medical students took part in the pilot study. The video simulation in the pilot study involved a prototype of the video simulator programmed by the first author and the live simulation employed trained student assistants as actors. Participants diagnosed one case in the video simulation and one case in the live simulation; the sequence of the simulations was randomized. Initial results of the pilot study showed that participants displayed slightly higher diagnostic accuracy in video simulations than in live simulations, and that live simulations were perceived as more authentic than video simulations (Fink et al., 2018 ). Because of technical problems with the video simulation, a computer scientist produced a professionally programmed video simulation for the validation study. It also became evident that non-professional actors in the live simulation did not act in a highly standardized and authentic way. Therefore, professional actors with experience as standardized patients rather than student assistants were trained to act in the live simulation for the validation study.

To evaluate the authenticity and difficulty of the nine developed case vignettes, an expert workshop with N  = 8 licensed physicians was conducted. The physicians judged seven case vignettes as authentic and of adequate difficulty for the study and suggested major revisions to two cases. Modifications were made accordingly before all scripts for the video simulation were filmed and before actors prepared for the live simulation.

A total of N  = 86 medical students took part in the validation study. The study used a mixed design with the between factor expertise (novices vs. interns) and the within factor sequence (video simulations—live simulations vs. live simulations—video simulations). Participants were eligible if they were either in the first 2 years of the clinical part of their university education (novices) or in their final clinical year (interns). Moreover, participants had to be fluent in German to rule out possible effects of language competence. The study used the final live and video simulations presented in this chapter. Participants were randomly assigned to one of the two sequences and took part in a pretest of conceptual and strategic knowledge and then solved three cases in each sequence. Initial findings indicate higher diagnostic accuracy of student participants in live than in video simulations (Fink et al., 2019 ). These findings are opposed to the findings of the pilot study. Due to the revised simulations, the larger sample, and the higher number of cases, the results of the validation study seem more reliable. Moreover, similarly to the pilot study, live simulations were perceived as more authentic than video simulations. The created knowledge tests were reliable and differentiated between novices and interns. In correlational analyses of the validity of the different knowledge tests and simulations, strategic and conceptual knowledge correlated positively with diagnostic performance in the simulations. Both types of knowledge correlated positively with each other.

All in all, the reported findings demonstrate that live simulations are suitable for the reliable and valid assessment of diagnostic competences in history-taking and offer even higher interactivity and authenticity than video simulations. The created video simulations may still require certain changes, such as longer familiarization with the history-taking menu, to achieve comparable validity and reliability to live simulations and may then be suitable for the economical and standardized assessment of medical interviewing skills. The validity and reliability of the developed knowledge tests were confirmed .

9.2.9 Conclusion Summary

This chapter reported on the theoretical background and the design, development, and validation process of a research project investigating the facilitation of diagnostic competences in live and video history-taking simulations.

In the section on the theoretical background, the summarized models of history-taking showed that a physician-centered approach to history-taking that emphasizes the functions of gathering data and making diagnoses is suitable for the assessment of diagnostic competences in experimental settings. Moreover, the section on diagnostic competences in the medical interview adapted the conceptual model presented in Chap. 2 to history-taking by presenting sensible operationalizations of diagnostic accuracy, delineating the major diagnostic activities (i.e., generating hypotheses, generating and evaluating evidence and drawing conclusions), and specifying the topics relevant for the assessment of professional knowledge in this situation. In addition, possible benefits and drawbacks of live simulations, video simulations and role-plays were outlined. The summary of key findings on training and assessing history-taking with simulations demonstrated that the differential effects of role-taking and reflection phases need further research.

The section on the design, development, and validation process highlighted the importance of systematic design, expert workshops, pilot studies and validation studies. It contains materials and operationalizations for future studies and programs seeking to design interactive history-taking simulations. The presented materials also show how comparable live and video simulations can be designed and developed. Findings from the validation study suggest that the created simulations may be employed after making minor changes, and the knowledge tests assess separate but related aspects of diagnostic competences validly and reliably.

9.2.10 Open Questions for Research

In line with Question 2 of the overarching research questions mentioned in the introduction by Fischer and Opitz (2022), future studies within this project will investigate the effect of instructional support measures on the acquisition of diagnostic competences. More precisely, the project will examine the effect of reflection phases and role-taking in live and video simulations and role-plays. Even though reflection phases have been shown to be effective instructional support measures (Mamede et al., 2008 , 2012 ; Mann et al., 2009 ), it is currently not clear whether reflection in video simulations during problem-solving or after problem-solving is more effective and what learning mechanisms, such as the application of certain types of professional knowledge, make reflection phases effective. Another open research question that also contributes to Question 2 of the overarching research questions described in the introduction by Fischer and Opitz (2022) pertains to the effect of roles in live simulations. Learners in live history-taking simulations can learn to take on the roles of a physician, a patient and an observer. While it has been shown that learning in the agent role is effective, there is a scarcity of findings on the patient and observer role (Cook, 2014 ). As also pointed out for reflection phases, it must be investigated what learning mechanisms arise in different roles. Finally, the effects of roles and reflection phases should also be explored in role-plays. Only a few findings on this topic are available, and these results do not directly relate to diagnostic competences but typically to communication skills (e.g., Lane & Rollnick, 2007 ).

The project also plans to contribute new findings to the overarching research question 4 mentioned in the introduction by Fischer and Opitz (2022), which addresses how simulations can be adapted to fit learners. We believe an especially interesting question concerns how adaptive scaffolding could facilitate diagnostic competences in video history-taking simulations. One interesting type of adaptive scaffolding to investigate would be the individual selection of cases of suitable typicality for learners. Case typicality denotes the degree to which a certain case corresponds with the prototypical signs and symptoms of a diagnosis (Papa, 2016 ). Learners could benefit from adapted case typicality by learning on optimally challenging cases in their zone of proximal development, scaffolded by instructional support (Vygotsky, 1978 ). Another interesting type of scaffolding to examine would be the adaptive use of reflection phases or examples. It is currently not clear whether the meta-analytical finding that examples are more beneficial for novices than reflection phases and reflection phases are more beneficial for advanced learners than examples (Chernikova et al., 2019 ) can be replicated in an experimental setting. Furthermore, it is unknown how reflection phases and examples interact in simulation-based learning from atypical cases.

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Acknowledgments

The research presented in this chapter was funded by a grant from the Deutsche Forschungsgemeinschaft (DFG-FOR 2385) to Martin R. Fischer, Frank Fischer, and Matthias Siebeck (FI 720/8-1).

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Fink, M.C., Reitmeier, V., Siebeck, M., Fischer, F., Fischer, M.R. (2022). Live and Video Simulations of Medical History-Taking: Theoretical Background, Design, Development, and Validation of a Learning Environment. In: Fischer, F., Opitz, A. (eds) Learning to Diagnose with Simulations . Springer, Cham. https://doi.org/10.1007/978-3-030-89147-3_9

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• Published: 15 December 2017

Clinical examination & record-keeping: Part 2: History taking

• A. M. Hadden 1 &

and the FGDP(UK) Clinical Examination and Record-Keeping Working Group

British Dental Journal volume  223 ,  pages 823–825 ( 2017 ) Cite this article

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• Dental patient management
• Guidelines and law in dentistry

Discusses how information can be gathered from the patient prior to the chairside consultation with the clinician.

Provides guidance on collecting dental, medical and socio-behavioural history from patients.

Contains a useful quick reference list of recommendations for history taking, specifying whether elements are conditional, basic or aspirational.

This article is the second part of a BDJ series of Practice papers on the subject of clinical examination and related record keeping. The series is taken from the Faculty of General Dental Practice UK (FGDP[UK]) 2016 Good Practice Guidelines book on this topic, edited by A. M. Hadden. This particular article discusses history taking, where information may be gathered prior to the patient seeing the clinician or, in some cases, this may be carried out chairside by the individual. The information gathered can include a medical history, socio-behavioural history, and patient anxiety levels. It is important to note that throughout this article (and the BDJ series and associated FGDP[UK] book), the specific guidelines will be marked as follows: A: Aspirational, B: Basic, C: Conditional. Further information about this guideline notation system is provided in Part 1 of this series ( BDJ 2017; 223 : 765–768).

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Introduction

In many practices, some information is provided by the patient prior to the chairside consultation with the clinician. It can be helpful to obtain information in advance as not only can this save valuable chairside time, but it can also enable the patient to provide detail when they do not feel under pressure. Usually a form is given to the patient to complete on arrival or sometimes in advance of the first visit, and this article describes information that can be gathered. A summary of the recommendations is provided at the end of this article in Table 1 .

Pre-examination

While the objective of a pre-examination is to ensure adequate detail about the patient, this procedure can also assist in finding out why the patient is attending, and if they have any concerns or are seeking any particular treatment.

It is for the practitioner to decide how much detail should be collected at this stage, and this is something that may vary between different patients and practices. Forms for patient completion can be constructed by the practice accordingly.

The information in the 'pre-exam' comprises:

Personal information.

Medical history.

Socio-behavioural history.

Often this can be included in one form for the patient to complete.

The history and information may also include:

Previous dental history.

Reason for the patient attendance.

Financial detail. Where relevant, this can include information about payment mechanisms such as NHS, private, or capitation scheme.

Personal information

Details to be recorded during a pre-exam should include:

Date of birth. B

Parent/Guardian contact – If the patient is a child, then details of the person with 'parental responsibility' need to be recorded. This is usually self-evident when a family attends a practice and the child's record may simply note that parents attend. C

Information of the responsible party – If the patient is in any way dependent on others for example due to disability, limited capacity, or as a vulnerable adult, full information of the responsible party (eg carer, next of kin) should be recorded. C

Phone numbers. These should include home, work, and mobile. The preferred contact number should be clearly indicated. A method of communication should be agreed and noted. B

Email address. C

Emergency contact details. B

Patient's General Medical Practitioner (GMP), and contact details (although this may be available on the medical history form). B

Relevant specialist practitioners, and contact details. C

NHS identification number (where required, to confirm eligibility for NHS care). C

Occupation. B

Patient's signature (or that of the responsible party) – for verification details of various forms, or on requests for information. B

Not all the above information will be available or necessary for every patient and it is for the practitioner to decide the level of information required for patient care and safety.

Medical history

Understanding a patient's medical history and being aware of the patient's medical condition throughout the time of providing care is essential 1 as medical care may influence the dental care provided. There are many conditions which can have a bearing on the dental treatment, and the clinician should be aware of the compromises necessary when treating patients with particular medical conditions or problems. It is not the purpose of this book to describe these in detail. The medical history must be recorded, and updated as necessary. (Example forms are included in Appendices 3a and 3b in the FGDP[UK] Good Practice Guidelines.)

Prevention of a problem, by use of risk management, is useful and a method of highlighting relevant information should be adopted. Examples include penicillin allergy, or patients taking anticoagulants.

There are many examples of medical history forms available commercially, and some practices will produce their own (see Appendix 3 in the FGDP[UK] Good Practice Guidelines). Guidance on the completion of the questionnaire should be given when appropriate, eg language difficulties, mental or physical impairment. In order to gain the most accurate information, a clinician should work through the questionnaire in collaboration with the patient. 2 , 3 It should be established that the patient fully understands each question. Clinicians should satisfy themselves that the information is correct and explore any area of ambiguity or concern, seeking clarification and obtaining details as required. Once complete, the form should be signed and dated by the patient, (unless software does not permit this – see part 3 of this BDJ series or chapter 8 in the FGDP[UK] Good Practice Guidelines), and by the clinician.

Although there may be notices in the practice such as in the waiting room, or at reception, asking patients to inform the dentist of any changes to their medical history, particularly medication, it is easy for the patient to forget, unless prompted. It follows that the medical history should be checked, but not necessarily recorded, at each appointment where invasive treatment is to be carried out. Any changes should be noted, dated, and initialled.

At a recall exam the medical history should be confirmed, dated, and initialled by the patient and the dentist. This form can be 'pp' on behalf of the dentist by a suitably trained DCP who would verbally advise the dentist of change, if any, so that the dentist is informed. Any changes should be noted, the form dated and initialled by the patient (unless software does not permit this – see part 3 of this BDJ series or chapter 8 in the FGDP[UK] Good Practice Guidelines) and the treating clinician.

Socio-behavioural history

This may be included as part of the medical history form. It can include:

Tobacco/smoking habit. B

Alcohol consumption. B

Recreational drug use (the patient may not wish to divulge). A

Eating habits. A

Dietary information (where relevant). C

Participation in contact sports. C

Playing of musical instrument involving use of mouth. C

It may be easier for the clinician to discuss these above points directly with the patient at chairside, however having the questions on a form given to the patient will help stimulate the patient's thoughts in these areas.

Previous dental history

This information can be sought with a suitably worded form, or as part of the medical history form, and completed by the patient prior to consultation. Prior to the formal first clinical examination, the dental history should record details of previous dental care (eg orthodontic and/or implant treatment), including analgesia/anaesthetics, any oral allergic reactions not recorded in the medical history, and any other information that the patient volunteers.

Useful information would include:

The ability and confidence to chew foods comfortably. 4 , 5 , 6 B

Previous restorative procedures involving fixed and removable prostheses. B

Orthodontic treatment. C

Endodontic treatment. C

Implant treatment. C

Previous periodontal conditions and or treatments. C

Previous difficulties. C

Oral surgery procedures. C

Oral hygiene regime (tooth brushing, oral hygiene aids, mouthwash). B

Unease, apprehension, or anxiety and fear of dentistry. B

Good or bad experience with dentistry. C

Aesthetic concerns in respect of their teeth. C

Changes that the patient has noticed within their own oral cavity. C

History of fissure sealants or preventative treatment provided by schools dentist C

Anything else the patient mentions. C

It is a matter of the clinician's personal preference whether to discuss the patient's dental history directly with the patient as part of general history taking or to provide the patient with a form to complete prior to chairside consultation. By using the form completed by the patient, the dentist can make additional notes on the same form for clarification as required.

When a new patient attends with a dental phobia it can be useful to assess the patient's condition quantitatively. This could, in turn, significantly modify the clinical management of the patient. Whilst there are many ways of measuring anxiety, the Modified Dental Anxiety Scale 7 (see appendix 11 in the FGDP[UK] Good Practice Guidelines) is a five-question, self-completion questionnaire that asks patients to rank their anxiety on a five-point scale ranging from 'not anxious' to 'extremely anxious'. It has proven to be a highly reliable and valid method of indicating a patient's anxiety status. Alternatively, a more subjective questionnaire, which includes more social aspects can be used (see appendix 10 in the FGDP[UK] Good Practice Guidelines). 8

Reason for patient attendance

This question can be included in the form given to the patient prior to consultation. However, many clinicians may prefer to ask the question directly at chairside. It is important to discuss this with the patient during the consultation to ensure an accurate understanding of the patient's needs and expectations. B

General patient management

Some clinicians will prefer to discuss much of the above at chairside, and this can help relax the nervous patient prior to examination. The most important point is that personal details and medical histories should be recorded. This is an essential part of information to be retained at each type of exam discussed in this book.

Other information that can be included:

An agreed method of contacting the patient, to avoid any ethical or confidentiality issues. A

Availability to attend appointments. A

Whether a carer is required to be present. C

Best time for an appointment. A

Patient's mobility, eg coping with stairs. C

Travel considerations. A

Patient attitude to dental health

It is helpful to understand a patient's attitude to dental care, and to see if the patient has any particular aims of treatment. (A questionnaire, such as the one provided in appendix 10 in the FGDP[UK] Good Practice Guidelines may be helpful).

Box 3: Faculty of General Dental Practice - Good Practice Guidelines

The Faculty of General Dental Practice (FGDP[UK]) provides evidence-based guidance and standards for the whole of the dental profession in order to promote high quality practice and patient care. Their publications are available in variety of formats including hard copy, e-books, and free of charge online as part of the Open Standards Intiative.

Clinical Examination and Record-Keeping is a complete reference guide to record-keeping and examination, and is available in hard copy and free of charge online. The hard copy includes scenarios to put the guidance into context, as well as a series of extensive appendices, diagrams, charting notes and template forms which dental and professionals may adopt for use in their practice.

The FGDP(UK) published its newest guidelines, Dementia-Friendly Dentistry: Good Practice Guidelines in October 2017.

For more information about all FGDP(UK) standards and guidance, visit: www.fgdp.org.uk/guidance-standards

Box 2: History information to be recorded

Medical history information to be recorded at pre-exam, recall exam, emergency dental, emergency trauma, and on receiving referral:

New form completed or updated. B

Dated and signed by patient and clinician. A

Box 1: Clincial Examination & Record-Keeping*

Part 1. Dental Records

Part 2. History Taking

Part 3. Electronic Records

*This series represents chapters 2, 3, and 8 from the FGDP(UK) Good Practice Guidelines entitled Clinical Examination & Record-Keeping , which is available online at https://www.fgdp.org.uk/guidance-standards . The content herein is reproduced with kind permission of FGDP(UK).

General Dental Council, Standards, Guidance, Standard 4.1.1, 2013. Available online at https://www.gdc-uk.org/api/files/NEW%20Standards%20for%20the%20Dental%20Team.pdf (accessed November 2017).

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Hadden, A., and the FGDP(UK) Clinical Examination and Record-Keeping Working Group. Clinical examination & record-keeping: Part 2: History taking. Br Dent J 223 , 823–825 (2017). https://doi.org/10.1038/sj.bdj.2017.989

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Patient Presentation and History

Chief Complaint: the patient’s wife is bringing the patient in after a fall at their home

Presentation:

J.S. a 50-year-old African American male who presents with his wife after he fell at home. After the fall, he told his wife “I will be fine, I think my vision just needs checked.” The patient reports, “I was walking very fast because I really had to pee and I accidentally ran into the table and got off balance. The next thing you know I was on the ground.” The patient reports having blurred vision for the past couple of months but just has not had the time to go to the eye doctor. His wife is more concerned about other changes she has noticed such as, J.S. has been waking up 3 times a night to go to the bathroom and he has had slight confusion and forgetfulness at times. J.S. thinks he has been using the bathroom more frequently because he has been so thirsty lately due to the warmer weather. When asked further about the fall the patient does report some tingling in both his feet occasionally. The patient’s wife also thinks her husband’s legs are getting weaker because he hasn’t been able to go on as long of a walk, like they normally do.  She also expressed concern about a cut J.S. got on his leg that has not healed. The patient believes he got the cut about 2 months ago while mowing the lawn.

Past Medical History:

Obesity (1999)                                                                                           

GERD (2005)                                                  

Anxiety (2015)

Obstructive Sleep Apnea (2017)

Surgical History:

Appendectomy (1995)

Tonsillectomy (2017)

Pertinent family history:

Father—alive; type 2 diabetes, hypertension

Mother—hyperlipidemia, died of a stroke at age 70

Sister—alive, unremarkable medical history

Pertinent Social history:

J.S. works at a bank where he is primarily sitting at a desk all day. He reports  gaining more weight recently so he and his wife have started going on walks around the neighborhood each night for exercise. He reports it is hard for him to eat healthy because he works long hours and “fast food is easy”. J.S. does report having “a bad smoking habit” of half a pack a day (12 pack years). He says it helps with his anxiety and stress of his job. The patient only reports social drinking (~2 drinks per week).

  Current Medications:

Xanax-.5 mg BID

Prilosec-20 mg Daily

  Assessment & Vitals:

Height: 5’9”

Weight: 255 lbs.

Temp: 98.7°F

P: 85 bpm, apically, regular rhythm

RR: 16 breaths/minute, unlabored

BP: 127/78 mmHg, left arm, sitting

Pain: patient reports no pain at this time

Skin: open cut on lower left leg ~2 inches in length, erythema surrounding cut, no drainage

Peripheral neurovascular: positive for tingling in bilateral lower extremities

  Lab Results:

Lipid panel:

         HDL: 45 mg/dL

         LDL: 105 mg/dL

        Triglycerides: 140 mg/dL

         Total: 190 mg/dL

Fasting blood glucose: 240

TSH: 2.0 mU/L

Urine Analysis: normal except:

        Glucose: 3.0 mmol/L

Chem 7: within normal limits

Michael Anthony Roxas, OD

Case history taking, the most important part of an eye exam (or any medical exam in particular).

Table of contents

Does the patient have learning problems or has difficulty in communicating, does the patient require support as a human being, does the patient require a more sophisticated care due to presence of eye diseases such as cataracts, glaucoma, or retinopathy, does the patient simply require correction for his visual needs, the minimum information to obtain in taking the case history:.

For the longest time, I thought the refraction exam was the most important part of the eye exam until I realized how critical case history taking is. I was always so eager to get into the eye examination to move on to the next patient, then I unintentionally find myself wasting both my patient's and my time because I didn't ask for any systemic conditions such as diabetes in the first place--resulting in a fluctuation of refractive errors.

The last thing you want to do as an optometrist is to provide the wrong solutions to a specific problem.

Case history taking is the part of the eye exam wherein you develop a picture of your patient's perspective on the visual problem. It is the duty of the optometrist to listen, understand, clarify misheard words, interpret, and summarize the words of the patient.

The aims of gaining such information include:

1. Identifying the complaints. The patient's first uttered words regarding the visual problem is usually considered as the chief complaint , the rest is known as associated complaints.

The most common is the blurring of vision , you will have to expound on this whether the patient experiences this at distance, at near, or both.

Other common mentions would be headaches and/or dizziness as their chief complaint. If this is the case, you have to determine whether the source of the anomaly is purely a refractive error or stress-related.

Furthermore, it is ideal to address all complaints for patient satisfaction. But sometimes the solutions can be counterproductive to each other, so the best approach is to at least address the chief complaint from a different approach.

A 45-year old female patient consulted for blurring of vision at near, she despises the use of spectacles and was suggested for contact lens use. Contact lens exam determined that she was not qualified for contact lenses due to severe dry eye. Her nature of work included sitting in an enclosed space with air-conditioning on, it was also observed that she was not organized and hygienic with her personal belongings.

Now, if this were your patient, you could probably convince her to wear reading glasses in your clinic but there's no guarantee that she would use them for reading (kasi nga ayaw sa glasses) . On the other hand, she may not qualify for contact lens use because her hygiene and sanitary habits may cause further problems in the near future.

SOLUTION: Suggest the use of magnifying lenses for viewing near objects.

2. Understand how the complaints affect the quality of life. Is the patient's productivity reduced due to his affected vision? Is he able to socialize well? Does he have difficulty recognizing friends and family? How difficult can he perform on his daily activities?

While it is ideal to restore the patient's quality of life before having to experience visual anomalies, this is not always the case. Especially if the solution can be hazardous in the patient's occupation. (i.e. a professional basketball player wearing spectacles in-game is not advised.)

3. Determine if the patient requires additional tests to address the visual problem. To be able to see comfortably clear is an optometrist's main goal in every patient's visual needs, a secondary goal would be to maximize vision.

There will be cases where there would be other tests to perform according to the patient's needs, this includes:

• contact lens examination
• color blind test
• sports vision assessment
• low vision assessment

4. Determine if the patient needs a referral. You should identify your stand in addressing the patient's problem in terms of learning, support, care, or correction?

He could probably be referred to a speech therapist after the eye exam.

A patient who has lost his vision in one eye could be due to evisceration or enucleation may regain his confidence outdoors with the help of a prosthetic eye

Addressing any form of anomalies is a must before prescribing any correction lenses to the patient. A referral to an ophthalmologist is the most appropriate step in this case before consulting an optometrist.

If the above areas are at optimum, then the patient may only need intervention in terms of correction or therapy through lenses and ocular exercises. By default, an optometrist should be able to provide these solutions.

• reason for consultation
• chief complaint and associated complaints
• hours of sleep
• social life (alcohol, smoking)
• daily activities that require vision (driving, reading)
• comorbidities and medical history

Case history taking is one of the most underrated portions of an eye exam, if you do this well you're doing yourself and your patient a huge favor.

With experience, the practitioner gets better with creativity and critical thinking.

A consequence of a sincere taking of the case history is the building of rapport between the optometrist and the patient. Not only does this develop trust but also a high chance of having a recurring patient for periodical check-ups.

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Case study: 32-year-old male presenting with right lower quadrant abdominal pain.

Jaclyn M. Gell ; Peter F. Graves .

Affiliations

Last Update: November 22, 2022 .

• Case Presentation

A 32-year-old male with no significant past medical history presents to the emergency department with abdominal pain. He states the pain began a few days ago in the right lower quadrant of the abdomen and now feels as though it is spreading to the mid-abdomen.

He describes the pain as coming on suddenly and sharp in nature.   Since the onset, his pain started to improve until the morning of his presentation to the emergency department, when it acutely worsened. He says that the pain is much worse with movement.

The patient is concerned about a possible hernia as he does heavy lifting at work. Review of systems is negative, including no anorexia, no nausea or vomiting, no testicular pain or swelling, no urinary or bowel complaints, and no fevers or chills.

The patient denies prior abdominal surgeries. He does smoke a half pack of cigarettes a day, drinks alcohol socially, and denies any recreational drug use. He notes no inherited medical conditions in his family.

Vital signs on arrival:

• Blood pressure (BP) 120/73 
• Heart rate (HR) 60
• Temperature: 35.6 C
• Oxygen saturation: 98% on room air
• Height 5'10" (178 cm)
• Weight 154 lbs (70 kg)

Physical Exam

• General: Alert and oriented, in no apparent distress, although ambulates into the emergency room holding his abdomen.
• HEENT: Normocephalic, atraumatic, sclera anicteric.  Mucus membranes are moist.
• Cardiovascular (CV): Regular rate and rhythm, no murmurs, rubs, gallops
• Pulmonary: clear to auscultation bilaterally
• Abdomen: moderate tenderness to palpation in the right lower quadrant without rebound, guarding, or rigidity.  Bowel sounds are present throughout.  Negative psoas and obturator signs.
• Genitourinary (GU): genitalia examined in a standing position with a normal external exam, no masses felt with a cough, intact cremasteric reflex
• Back: No cerebrovascular (CVA) tenderness
• Neurological: No focal deficits
• Skin: Warm and dry, no rashes
• Initial Evaluation

Initial tests were performed, including blood testing consisting of a complete blood count (CBC), basic metabolic panel (BMP), lipase, and liver function test (LFT), as well as a urinalysis. Lab work was remarkable for no acute abnormalities except for a mild leukocytosis of 12.4.

• WBC 12.4 x 10 /mcl (81% neutrophils, 11% lymphocytes, 6% monocytes, 2% eosinophils, no bands)
• HGB/HCT 14.6/44.6 g/dl
• PLT 356 x 10 /mcl
• Gluc 93 mg/dl
• BUN/CR 17/1.08 mg/dl
• Na 138 mmol/L
• K 4.4 mmol/L
• Cl 107 mmol/L
• CO2 25 mmol/L
• Ca 9.7 mg/dl

Lipase 

• 40 Intl U/L
• Total bilirubin 0.3 (0.07 direct) mg/dl
• AST 17 Intl U/L
• ALT 15 Intl U/L
• AlkPhos 64 Intl U/L
• Total protein 6.76 g/dl 
• Clear yellow
• Negative for glucose, bilirubin, blood, protein, urobilinogen, nitrite, leukocyte esterase
• Trace ketones
• Sp gravity 1.027
• Differential Diagnosis

In a young, healthy adult male presenting with right lower quadrant abdominal pain, the differential diagnosis includes appendicitis, typhlitis, epiploic appendagitis, perforated viscous, inflammatory bowel disease, diverticulitis, small bowel obstruction, testicular torsion, epididymitis, hernia, urinary tract infection, and pyelonephritis. Extra-abdominal causes such as abdominal muscle strain or a hernia and skin disorders such as herpes zoster viral infection are less likely. [1]

• Confirmatory Evaluation

A CT scan with intravenous contrast was ordered. This was interpreted by the radiologist noting a blind ending. The inflamed appendage is emanating from the small bowel, with an incomplete superior wall and fluid layering in the deep pelvis, concerning for perforated Meckel diverticulum.  Surgical consultation was initiated in the emergency department, and the patient was taken to the operating room for an exploratory laparotomy confirming the diagnosis of perforated Meckel's diverticulum. The subsequent pathology report also noted Meckel's diverticulum with gastric heterotopia and feature consistent with perforation and serositis.

Meckel’s diverticulum is a congenital anomaly resulting from the abnormal embryonic separation of the omphalomesenteric duct. Meckel’s diverticulum is a true diverticulum comprised of all 3 layers of the gastrointestinal (GI) tract, including mucosa, submucosa, and adventitia. [2] Meckel’s diverticulum usually consists of heterotopic tissue, most commonly gastric mucosa, due to the pluripotential cell line of the omphalomesenteric duct. Other heterotopic tissue found on pathological specimens of Meckel's diverticulum may include pancreatic, jejunal, duodenal, and, less commonly, colonic, rectal, or endometrial. Epidemiologically, Meckel’s diverticulum tends to follow the rule of 2s: [2]

• Occurs in 2% of the population
• Located within 2 feet of the ileocecal valve
• Two centimeters in length
• Two times as likely to be symptomatic in young boys as compared to young girls
• Symptoms often present before the age of 2

Although Meckel's diverticulum is usually asymptomatic and may never be identified until autopsy reports, it can lead to serious complications, most notably hemorrhage, obstruction, perforation, or infection. Hemorrhage occurs secondary to acid secretion from the gastric mucosa that forms ulcerations along the intestinal mucosa and can lead to painless rectal bleeding, typically in children. Bleeding can be substantial and may require transfusions. [2]

The diverticulum can also serve as a lead point for an ileocolic or ileoileal intussusception, as well as a turning point for a volvulus. If symptomatic, patients typically complain of crampy, right lower quadrant abdominal pain. Finally, erosion of nearby intestinal mucosa or inflammation of the diverticulum itself can lead to perforation, or the diverticulum itself can become inflamed, leading to diverticulitis. [3]

Evaluation of a patient with suspected complications from Meckel's diverticulum includes multiple options. Lab testing is largely unremarkable, but hemoglobin and hematocrit should be checked as mild to moderate anemia may develop if there is bleeding. If there is significant bleeding, transfusions may be necessary. Electrolyte levels and kidney function testing are not helpful for diagnosis but can help guide treatment options. [1]

Multiple imaging modalities exist to evaluate suspected Meckel's diverticulum. If a patient, especially a young child, presents with GI bleeding, the test of choice is a technetium-99 pertechnetate scintiscan. The pertechnetate will be absorbed by the gastric mucosa and will be detected when scanned by a gamma camera. This is the preferred scan due to ease and accuracy; however, false negative tests do occur if the diverticulum is comprised of other tissue other than gastric mucosa. [4]

If intestinal obstruction or perforation of Meckel's diverticulum is suspected, then a CT scan may be helpful, whereas ultrasonography has been useful if the clinical picture suggests intussusception. Overall, Meckel's diverticulum may be found incidentally on routine imaging or during a surgical procedure or may only be recognized when complications arise. [1]

In many cases, the diverticulum is found incidentally on laparotomy or laparoscopy, and it becomes the surgeon’s decision on whether or not to remove the diverticulum to prevent future complications. The lifetime risk of complications is 4.2%, and the risk decreases with age. [1] Therefore, the decision for diverticulectomy is favored in asymptomatic patients who are young and have a long diverticulum (typically greater than 2 cm) with a narrow neck and fibrous banding or if it appears to be comprised of gastric mucosa and is inflamed or thickened. However, in a symptomatic patient, medical management is limited to supportive care, including possible antibiotic administration, and surgical resection is required for definitive treatment. [1]

Abdominal pain is an extremely common complaint in the emergency department, with a large differential ranging from very benign etiologies to life-threatening emergencies. Keeping a large differential can help guide diagnosis and treatment options. Although relatively rare, serious complications can arise in someone with Meckel's diverticulum and the definitive treatment is a surgical intervention for removal and repair. Meckel's diverticulum is often an incidental finding, and if found during surgery, removal is typically up to the discretion of the surgeon. Surgeons have determined certain guidelines to drive their decision to remove an asymptomatic diverticulum to prevent future complications. [1]

These parameters are listed above but include younger age, diverticulum lengths greater than 2 centimeters, presence of gastric mucosa, and male gender. However, there is no significant evidence to determine whether or not this approach changes morbidity or mortality. If painless rectal bleeding is the presenting symptom, a technetium-99 scan may be appropriate for diagnosis. However, for patients that present with abdominal pain and physical exam concerning for perforation, intestinal obstruction, or intra-abdominal abscess,  a CT scan is more appropriate for diagnosis. After diagnosis, prompt surgical consultation and operative management are necessary. [4]

• Pearls of Wisdom

Meckel's diverticulum is a rare diagnosis in adults but should always be on the differential of patients who present with lower abdominal bleeding or abdominal pain.

Meckel's diverticulum, which contains gastric tissue, may be detected with a technetium-99 scan, which is an appropriate first imaging test in patients with painless lower abdominal bleeding.

Remember "the rule of 2s:"

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• Comment on this article.

Perforated Meckel's Diverticulum CT scans Contributed by Peter Graves, MD, FACEP

Disclosure: Jaclyn Gell declares no relevant financial relationships with ineligible companies.

Disclosure: Peter Graves declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

• Cite this Page Gell JM, Graves PF. Case Study: 32-Year-Old Male Presenting with Right Lower Quadrant Abdominal Pain. [Updated 2022 Nov 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

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