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

Introduction

As a certified physician, the ability to gather an accurate medical history through patient interviews is an essential skill. The process of eliciting relevant personal, psychosocial, and symptom information from a patient is defined as “history-taking”, which contributes to obtaining useful information in formulating a diagnosis and providing medical care to the patient (Keifenheim et al., 2015). Despite numerous technological advancements, such as imaging and genetic testing, that have significantly altered medical diagnosis and treatment over the past few decades, none of these scientific advances can completely replace clinical history-taking, which is considered a fundamental core competency of a physician (Novack et al., 1993). This is because collecting a patient’s medical history through interviews could significantly aid in determining the severity of a patient’s condition, identifying primary issues, and responding to patients’ emotions (Fortin et al., 2002; Hatem et al., 2007). Consequently, training in interviewing skills for obtaining a clinical history has long been a major component of medical education.

Effective communication within the medical interview contributes to the accuracy of diagnoses. Medical educators continue to emphasize the importance of teaching communication skills, as evidenced by the United States Medical Licensing Examination (USMLE) testing both the integrated clinical encounter (ICE) and communication and interpersonal skills (CIS) within the Step 2 Clinical Skills exam (CS) (Dong et al., 2015). However, it is difficult to assess communication skills through inauthentic means, such as a written test, because it requires in vivo demonstration. As a result, the objective structured clinical examination (OSCE), an assessment designed to measure the performance of medical tasks in a high-fidelity way, has been extensively employed to evaluate the effectiveness of medical students’ history-taking and communication skills (Jani et al., 2020). OSCE was firstly introduced in 1975 as a standardized tool for objectively assessing clinical competencies, including history-taking, physical examination, communication skills, data interpretation etc (Khan et al., 2013). On OSCE, medical students’ performance typically varies with rating scales and/or checklists by supervisory clinician examiners, indicating that OSCE provides a relatively fair and accurate measurement for evaluating medical students’ competency in communication, history-taking, physical examination, clinical case analysis, application of medical knowledge, and integration of fundamental clinical skills, which are required for future clinical practice (Cömert et al., 2016). Due to its advantages in comprehensively examining the clinical competencies of medical students/trainees (Ananthakrishnan, 1993; Huber, 2003), we were able to objectively evaluate medical students’ performance in a simulated work environment of OSCE, which is strictly designed to be as close to real-world scenarios as possible for future practice (Ghouri et al., 2018).

In the contemporary world, many medical schools and regulatory authorities attempt to establish accurate and reliable competency assessments to evaluate the learning outcomes of medical students, interns, and trainees. The National Medical Licensing Examination (NMLE) system has been developed in many countries to control the quality of newly licensed physicians in everyday medical practice (Han et al., 2020). In China, the NMLE has been implemented for more than two decades since the promulgation of the Law on Practicing Doctors in 1999 (Wu et al., 2014; Xin, Su & Yang, 2009; Shi, 2010). At the same time, the National Medical Examination Center (NMEC) launched the Clinical Medicine Level Test (CMLT) before medical students’ final-year internship, as a valid and reliable assessment for assessing their learning outcomes in both basic and clinical medical sciences. CMLT is administered in most medical universities, and is regarded as a pretest of the NMLE because it usually exhibits the same tendency as the NMLE, as reported by NMEC. The results of CMLT, which is administrated one to two years before NMLE at most medical schools, are regarded as a predictor and guide for subsequent undergraduate and postgraduate education, as well as residency training. Both NMLE and CMLT have the same design and contain two aspects: one is related to the cognitive component assessed by a written examination, while the other is clinical skills assessed by OSCE. Epstein stated that the objectives of the assessments in medical education are: (1) assessment of analytical and problem-solving abilities; (2) identification of incompetent physicians; and (3) selection of applicants for advanced training (Epstein, 2007). Therefore, CMLT not only identifies students early in their training whose clinical skills are developing slower than their peers, but also helps investigate the problems in current medical education that need to be addressed.

Through analyzing the medical students’ CMLT scores and collecting their feedback, this study has the following purposes: 1. Identifying the gaps between our current teaching approaches and development of medical students’ clinical abilities; 2. Establishing some post-intervention practice to cover the gaps; and 3. Improving the quality of medical students training continuously. The problem focused in this study is the deficiencies in medical history-taking training identified by CMLT score analyzing, and subsequent corrective interventions.

Methods

Participants and CMLT

In total, 168 students at Jinan University School of Medicine attended the CMLT. These participants were fourth-year undergraduates in clinical medicine who were enrolled in 2017. The examinees were 91 (54.17%) male and 77 (45.83%) female students; the average age was 22.42  ± 1.18 years old; 129 (76.79%) students were from mainland China and 39 (23.21%) were from overseas; 147 (87.50%) students studied medicine in Chinese, and 21 (12.50%) students studied medicine in English. In the spring semester of 2021, the CMLT was administered to medical students who were in the final year of their studies, prior to their internships. The examination included both written and OSCE components, with six stations covering medical history-taking, physical examinations, cardiopulmonary resuscitation, blood collection by venipuncture, and surgical suturing (Fig. 1). The results of the examination at each of the six stations were compiled by subject and categorized into four groups: internal medicine operation, emergency operation, surgical operation, and medical history-taking. The four parts were statistically described and analyzed. To enable comparison of scores, the T-score normalization method was used for OSCE scores of medical students, based on a previous report (Williams et al., 2019).

Results

Discussion

Prior to internships in China, the CMLT evaluates the effectiveness of teaching and the learning outcomes of medical students. Although not yet mandatory for all Chinese medical students, accumulated experience in recent years has shown that it is beneficial in increasing the practitioners’ NMLE passing rate (Lio et al., 2016; Zhang et al., 2019).

This study initially compared the CMLT performance of several groups of medical student cohorts at Jinan University School of Medicine in 2021. The primary conclusion of the analysis was that clinical history-taking had poor performance, indicating that there may be inherent or external factors affecting the learning outcomes of medical students. Subsequently, we focused on the causes of medical students’ unsatisfactory performance in taking patients histories. We conducted an analysis of the specific variation to provide useful information for enhancing the effectiveness of history-taking instruction.

In recent decades, medical history-taking has been prioritized in clinical medical education, with numerous medical schools developing consensus guidelines emphasizing its significance (Novack et al., 1993). Clinical history-taking is considered an efficient way of obtaining more complete and accurate patient information to guide disease diagnosis and treatment (Keifenheim et al., 2015; Schechter et al., 1996), and interpersonal ability is also considered a core skell of a qualified physician (Hargie et al., 1998; Novack et al., 1993). Retired physician David Levine said that listening to patients is not enough, as history taking is a complex skill that requires skilled clinical reasoning to choose the right questions and interpret the answers to decide what to ask or do next (Levine, 2017). Deliberate practice from seeing more cases is an effective way to improve skills, but formal training is necessary for inexperienced medical students. In this study, we found that our medical students’ performance was generally unsatisfactory in history-taking, especially when compared to emergency cardiopulmonory resuscitation (CPR), and surgical procedures such as suturing, fixation, and bandaging (Tables 1–3). The principal factor analysis of the questionnaire from the participating students revealed that the students recognized the importance of history-taking skills, and had some evaluations and suggestions for effective history-taking training (Table 4). This result indicated that the students were eager to develop their history-taking skills.

On the other hand, the students were dissatisfied with the current teaching approaches for medical history-taking, and they wished for more opportunities to contact actual patients or be trained with SPs that could mimic clinical scenarios while reducing the time for classroom instruction on history-taking (Table 5). This attitude echoes a previous report in which training students in history-taking skills with televised demonstrations and SPs was more efficient than traditional formats (Maguire, Clarke & Jolley, 1977). Furthermore, this simulation training would greatly encourage medical students to shift from a traditional “questioning style” to a “functional model”, educating patients and influencing their attitudes towards the diseases they suffer from, rather than simply collecting patients’ physical condition (Keifenheim et al., 2015). Skills of communication, clinical reasoning and summary are used during medical history-taking. These non-technical skills are elements of high-level cognition, especially some of while are related to medical humanity education, which is hard to define and unify because humanistic education requires inter-professionals and its methods can vary (Spence et al., 2020). Therefore, educator are exploring the most effective methods and the optimal timing of history-taking training.

Regarding the improvement of medical students’ history-taking skills, Keifenheim et al. suggested several educational interventions. These include implementing small group workshops that involve role-playing and interviews with real patients, discussing the most common and best cases among the participants, and promoting instructive experiences and lessons through videotape reviews etc (Keifenheim et al., 2015). In light of our survey results, we incorporated history-taking workshops with SP into pre-internship training for medical students before they started their medical internships in the last academic year. Feedback from participating students revealed that the workshops were effective in helping them understand the standard process of history-taking and competently applying it in practice. The workshops also broadened their medical knowledge and promoted learning enthusiasm (Table 6). This finding confirmed the notion that the history-taking skills required by qualified physicians are not innate and must be particularly and repeatedly practiced throughout medical education (Kraan et al., 1990; Pfeiffer et al., 1998). The real examination of this training’s outcome would be completed by means of evaluating students’ ability to obtain an accurate medical history from patients in clinical practice. This is also our ultimate objective for the education of training medical students at medical schools.

This study has several practice implications:

1. Communication skills for medical interviews should be emphasized through effective training methods.

2. SP training for practicing history-taking can be incorporated into the routine clinical training curriculum.

3. Simulative learning environments that can replicate every step of history-taking and allow students to spot minute errors are a successful teaching strategy.

Limitations of this Study

The present study has both strengths and limitations. The first limitation is that the conclusions were derived from one CMLT and the subsequent survey at Jinan University School of Medicine, so they may not be completely applicable to all teaching hospitals. There are numerous different teaching facilities and instructional strategies that could influence the perceptions of medical students regarding the advantages and disadvantages of medical education. Second, while we intended for the CMLT to reflect the educational situation of basic and clinical medicine and provide a beneficial supplement for the formal examination of doctors’ qualifications, there may be flaws in the structure, design and practical experience due to the limited time and scope of implementation.

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