ACADEMIA AND CLINIC

An Approach to Teaching the Introduction to Clinical Medicine JOCHANAN BENBASSAT, M.D., and ANNA SCHIFFMANN, M.D., Jerusalem, Israel

An approach to teaching the introduction of clinical medicine to medical students is described. It is based on (A) gradual exposure to patients and step-by-step introduction to the objectives and techniques of history taking, with emphasis on training for symptom identification; (B) early exposure to the problem-oriented approach; (C) early diagnostic hypothesis generation; and (D) self-directed learning. The objectives of the proposed approach are to teach students to communicate with patients, to teach the skills of history taking and physical examination, and to introduce the problem-solving strategies that characterize the diagnostic reasoning of experienced physicians.

finding could be to train students for early diagnostic hypothesis generation so that their performance would more closely resemble that of the expert physician. In this paper, we describe an approach to teaching the introduction to clinical medicine based on (A) a logically constructed standard format for recording, writing-up, and presenting the statement of the patient's various problems; (B) step-by-step introduction to the objectives and techniques of history taking; (C) provisional diagnostic hypotheses generation at every stage of history taking; and (D) self-directed learning. Method A. THE CASE HISTORY FORMAT

IN RESPONSE to the widespread criticism of existing methods of introduction to clinical medicine, there is a growing trend to facilitate the transition from preclinical to clinical studies by a thorough, step-by-step, systematic instruction in interviewing and history-recording techniques (1). However, even though recent texts (1, 2) describe techniques of data collection, analysis, and reporting, the methods suggested do not reflect those of experienced physicians faced with a clinical problem. As a result, inexperienced students may regard medical diagnosis as a by-product of passive data collection ("listen to the patient; he is telling you the diagnosis"). Because subject-matter competence is a major factor in the formulation of diagnostic hypotheses ultimately leading to management decisions, the novice student restricts himself to data collection. The student taught through such an educational strategy is therefore "programmed" for data collection rather than trained in the problem-solving strategies that characterize the diagnostic reasoning of experienced physicians. Elstein and associates (3) have shown that "the experienced physician appears to leap directly to a small array of provisional hypotheses very early in his encounter with the patient." Thus, the diagnostic reasoning of expert physicians is characterized by generation, testing, and acceptance or rejection of diagnostic hypotheses throughout the data-collection process. The educational application of this • From the Department of Medicine A and Medical Education, Hadassah University Hospital and Hebrew University-Hadassah Medical School, Jerusalem, Israel. Annals of Internal Medicine 84:477-481, 1976

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We have adopted the Weed format (4) in which the statement of the patient's present problem(s) consists of (A) description of the symptoms; (B) list of relevant negative data; (C) report of relevant objective data (for example, results of previous medical examinations); and (D) information about previous medical treatment. After the present problems(s) has been written up in this format, the case history is completed by the patient's past history, family history, and system review. This format has four advantages as compared with the traditional chronologic approach to the formulation of the statement of the present illness: (A) it provides the student with the ability to differentiate between the various categories of data and to present them in the sequence of their probable relative importance; (B) omissions are more easily detected, explained, and corrected; (C) communication of data is more efficient because the audience is "programmed" to receive them in the same order in which they are presented; and (D) concentration, selection, and grouping of the various data are, in themselves, an exercise in diagnostic reasoning (4). B. STEP-BY-STEP INTRODUCTION TO CLINICAL MEDICINE

As pointed out by Morgan and Engel (1), "student responsibility [should] progress in the course, beginning with partial interview experience and regional physical examination, and advancing to complete work-ups and presentations." Our method consists of a step-by-step introduction to clinical medicine based on the principle of "learning for mastery" (5). The skills of history taking and recording are subdivided into a set of clearly defined, se477

ing of history taking and recording. The teaching of physical examination, which was an integral part of each stage, is not reported in the present paper.

quentially taught, interim objectives. The student must master each objective before proceeding to the next one. Guided by precise and detailed instructions, students gradually develop technical skills. During each exercise, they receive a specific assignment: to concentrate on a single aspect of the case history. At the beginning of the course, several sessions are devoted to interview techniques. As the course progresses, the student is required to restrict his report to a specific aspect of the history in accordance with the stated objective for that session (for example, the patient's personality profile).

STAGE I.

Objectives: (A) To help the student communicate with patients and overcome his initial shyness, inhibitions, and natural reluctance to invade other people's privacy; (B) to demonstrate and train students for appropriate professional behavior (to refrain from expressing surprise, anger, or shock in response to patients' apearance and behavior); (C) to emphasize the central role of the case history in identifying the patient's problem(s) and in the diagnostic process. During the introductory sessions, students are warned that they may experience some initial embarrassment if patients talk about their emotional problems or show hostility. Using simulated patients, the instructor shows that appropriate professional attitudes and behavior may transform almost any medical interview into a positive experience for both patient and student. Students are then assigned to real patients and, after they have introduced themselves, are asked to talk to them for as long as the latter wish. The conversations do not necessarily have to revolve around the patient's illness, and no written reports are required. Students are instructed to refrain from interrupting the patient's spontaneous narrative and, if necessary, to encourage him to talk either by brief questions echoing the patient's last word, or by general questions such as: "Mr. , you mentioned a pain in the stomach. I'd like to hear more about it." Only after the patient seems to have completed his narrative is the student allowed to ask specific questions. The major emphasis during this stage is on developing proper attitudes towards patients, rather than on training in diagnostic reasoning. Problems that students may have encountered during the initial patient interviews are reviewed during the post interview discussion period. Various personality types (for example, dependent, shy, aggressive, emotional, patronizing) are demonstrated on real and simulated patients. Physical and behavorial manifestations of inadequate satisfaction of various psychophysiologic human needs (nutrition, love, a sense of security, acceptance by and belonging to a community, recognition, and esteem) are explored.

C. GENERATION OF PROVISIONAL HYPOTHESES

Elstein and associates' findings (3) indicate that hypotheses are generated at a very early stage of the diagnostic problem-solving process, and that history taking and the physical examination done by experienced physicians are guided by the testing, acceptance, or rejection of their early hypotheses. Therefore, during each stage of our course, students are taught to generate hypotheses as to the possible origin of the patient's symptoms, to defend their hypotheses, and suggest ways to test them. The instructor's functions are mainly to explain and demonstrate data collection techniques, to supervise students' performance in history taking and physical examination, and to help them manipulate diagnostic hypotheses. He is thus a mediator and not primarily a source of factual knowledge, which the students obtain through self-directed learning. D. SELF-DIRECTED LEARNING

Self-directed learning of signs and symptoms and of disease entities according to clearly defined overall and interim objectives constitutes the basic subject matter acquired by students. Instructor-guided discussions, clinical simulations, and video-tape recordings are used for assessing the extent to which students have mastered these objectives. The Course

Introduction to Clinical Medicine at the Hebrew University-Hadassah Medical School is taught during the third year of a 6-year undergraduate curriculum, prior to the beginning of the clinical clerkships. At the same time, students study pathology, microbiology, and human genetics. Our pilot-project course was implemented during the 1974-1975 academic year. It consisted of eight stages divided into 40 to 50 teaching sessions. During each session, small groups of students spent 2 to 3 hours on a medical ward under the guidance of an instructor. Each session included: (A) a statement of the objectives for that session; (B) interview and examination of a patient by one or two students; (C) an instructor-led group discussion of the case histories and reports of the physical examinations prepared by each student. These discussions centered around the analysis and defence of students' provisional diagnostic hypotheses; and (D) instructor's demonstration of abnormal physical findings. The following is a description of the stages of the teach478

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INTRODUCTION TO THE DOCTER-PATIENT

RELATION

STAGE II.

PERSONALITY PROFILE

Objective: To obtain and record the patient's personality profile, including sociodemographic data, and his conception of his condition and his life in general ( 6 ) . Patients are interviewed as during Stage I. After completing the interview, the students are required to prepare written reports on the patient's personality profile, for example: The patient is a 60-year-old Ashkenazy Jew born in Germany. He is married and has three children. He lives with his wife in a two-bedroom apartment. Until 2 weeks ago, his daily routine included work in his 4

carpentry workshop until 6 p.m. and rest at home in the evening. He describes himself as a hard and conscientious worker with no hobbies, having a generally happy family life, and having been healthy in the past. He is worried about this present disease and is pessimistic about his outcome. During the postinterview discussions, the diagnostic importance of the sociodemographic data and their relevance as diagnostic cues are explained. We find that making the student ask himself the question "What kind of person is the patient, and how does he view his disease and his life in general?" is an effective means of promoting a sympathetic and professional attitude towards the patient. STAGE III.

CHIEF COMPLAINT

Objective: To formulate and record the chief complaint and its duration. The chief complaint is defined as the immediate reason that led the patient to seek medical attention. By the beginning of this stage, the students have studied the symptomatology of the body systems. They now interview patients as in Stages I and II, but restrict their written reports to a description of the chief complaint, for example: "chest pain of 3 hours' duration on the day of admission"; or "bouts of diarrhea during the past 10 months"; or "none, patient referred with accidental finding of a round shadow on chest X ray." Complaints are discussed and grouped into categories: (A) pain; (B) symptoms due to organ dysfunction; (C) accidental findings; and (D) general symptoms (fever, loss of weight). Beginning at this stage, students are encouraged to generate provisional hypotheses regarding the origin of the patient's complaints, and to list additional symptoms which, if present, would support these hypotheses. Because our third-year students have not yet completed the pathology course, and are only supplied with partial information about the patient, they cannot be expected to present a differential diagnosis consisting of nosologic entities. Thus, their initial hypotheses are confined to designating the anatomic region from which the complaint originates, for example: "pain in the chest could be a manifestation of a disease of the heart, lung, or oesophagus; possible additional symptoms: dyspnea, cough, dysphagia"; or "epigastric pain could result from a disease in the stomach, duodenum, pancreas or gall bladder; possible additional symptoms: vomiting, heartburn, fat intolerance"; or "diarrhea could be caused by a disease of the small or large bowel; possible additional symptoms: abdominal pain, vomiting, tenesmus." The instructor is careful to select patients whose chief complaints are localized pain or symptoms of organ dysfunction where the differential diagnosis could be based on anatomic location. During these early stages of the course, the instructor demonstrates the technique of the physical examination of the various body systems. The systems are selected according to the patient's symptoms and the students' diagnoses. The student does a regional physical examination, looking for findings that could support his provisional hypothesis, for example: "dyspnea could be caused by a disease of the heart or of the lungs; in this patient it is probably a mani-

festation of a disease of the heart because the apex beat is displaced to the left and the heart rhythm is irregular", or "the epigastric pain in this patient may originate in the liver or the bile ducts as suggested by the presence of jaundice." STAGE IV.

SYMPTOMS

Objective: To identify and list the patient's symptoms. Students listen to the patient's narrative, paying special attention to symptoms, and list them in the order of their appearance. The required written report consists of the first two sentences of the statement of the present illness, for example: "The present illness started 3 years ago; its manifestations were bouts of chest pain, shortness of breath, and swelling of the legs"; or "The present illness began 3 days ago; its manifestations were fever (39 °C), shaking chills, dry cough, and sore throat." At this stage, students have to refrain from detailed descriptions of symptoms and their course. As in the previous stage, patients with a single problem, preferably localized pain, or organ dysfunction, or both, are assigned. If the student succeeds in identifying the diseased organ or system, he is then referred to appropriate sources and encouraged to suggest more specific diagnostic hypotheses, for example: "pain in the right flank and dysuria may be caused by disease of the urinary tract, possibly a bacterial infection or a stone" or "fever, cough, and pain in the chest of 2 days' duration may be due to an inflammation of the respiratory tract (for example, bronchitis or pneumonia)." Students are reminded that many patients' descriptions of what they felt are vague and ambiguous, and that they often tend to misuse medical terms, dwell on the results of previous examinations and therapy, and give their interpretation of other physicians' opinions. In such cases the symptomatology should be elicited by the use of probing, rather than leading, questions so that the patient will not be influenced by the students' provisional hypotheses. Instead of asking a patient with pain in the chest, "did you suffer from cough, shortness of breath or palpitations?" the student should encourage the patient to talk by asking general questions, such as "tell me more about the pain in your chest" or "was anything else bothering you?" Specific and leading questions should be asked only towards the end of the interview. STAGE V.

PROBLEMS

Objective: To introduce the student to the problemoriented approach. At this stage, patients with more than one problem are selected for interview and examination. Students now have to differentiate between groups of symptoms that may indicate different medical problems. The criteria for grouping symptoms are (A) obvious origin in the same organ system, and (B) similar duration, or simultaneous onset, or both. For example: 1. The present illness began 6 hours before hospitalization. Its manifestations were chest pain, profuse sweating, and palpitations. 2. During the past 10 years, the patient has comBenbassat and Schiffmann • Introduction to Clinical Medicine

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plained of bouts of epigastric pain and heartburn.

Weed format ( 4 ) .

The symptoms in the above example were grouped in two separate categories on the basis of their nonsimultaneous onset. They could have originated in two different organ systems (cardiovascular and gastrointestinal), and the patient could be suffering from two diseases (acute myocardial infarction and peptic ulcer). Alternatively, these two groups of symptoms could originate in the same organ system (gastrointestinal) and be manifestations of the same disease (perforated peptic ulcer). The various diagnostic hypotheses are considered during the postinterview discussions with the instructor. At such an early stage of the diagnostic interview, neither the expert physician nor the inexperienced student have sufficient information to test their alternative hypotheses. When there does not seem to be any obvious connection between two or more problems, it is much easier to deal with each one separately and only afterward to attempt to ascertain whether there is any connection between them. STAGE VI.

The present disease began 2 days ago with fever, abdominal pain, and diarrhea. All of these symptoms are still present. The fever is continuous and fluctuates between 38 and 39.5 °C. The pain is periumbilical and hypogastric. It is described as severe, intermittent, and aggravated during bowel movement. The patient has five to ten bowel movements a day of watery consistency, occasionally with mucous and blood. There were no vomiting, chills, or headache. Several hours after the onset of the symptoms, the patient was seen by a physician and told that he had dysentery. He was treated with 2 g ampicillin daily with no improvement. The available data suggest an acute inflammatory disease of the large intestine. After additional reading, the student is expected to propose a more specific differential diagnosis, for example: amoebic dysentery, shigellosis, or first bout of ulcerative colitis. STAGE IX.

Objective: To define and report the characteristics of the patient's symptoms that is, time of onset, quality, duration, frequency, course, aggravating and alleviating factors, associated symptoms. At this stage students begin to concentrate on prototypes of disease courses. Patients with typical case histories and physical findings of common diseases such as viral hepatitis, hyperthyroidism, angina pectoris, bronchiectases, peptic ulcer, ulcerative colitis, tonsilitis, cystopyelitis, rheumatoid arthritis, left and right congestive heart failure are assigned, thus enabling students to generate more specific provisional diagnoses. Once again, students are referred to texts and relevant audiovisual material and are asked to suggest a differential diagnosis at a higher level of resolution, for example, ascending cystopyelitis with causative microorganisms or congestive heart failure with possible cause. STATEMENT OF THE PRESENT

PROBLEM(S)

(CONTINUED)

Objective: To complete the symptom list and elicit "negative data," which are defined as symptoms, the absence of which may potentially serve as diagnostic cues. Students ask the patient about symptoms that they know originate from the same organ or system as the chief complaint, and record the answers, even if negative, for example: the lack of dyspnea or palpitations in a patient with pain in the chest, or the absence of pain in the flanks in a patient suffering from dysuria. STAGE VIII.

STATEMENT OF THE PRESENT

Discussion

We have presented an approach to teaching the introduction to clinical medicine centered on (A) gradual exposure to patients with intensive training for symptom identification; (B) early exposure to the problem-oriented approach; (C) early diagnostic hypothesis generation; (D) self-directed learning. Before teaching history-taking and physical-examination techniques, students are exposed to simulated and real patients. This introductory phase is very important because gradual exposure to patients, together with clearly defined objectives and specific instructions, helps students to over-

PROBLEM(S)

(CONTINUED)

Objective: To add objective data, previous medical findings, opinions, and treatment that the student considers relevant to the present illness. By the end of this stage, students should be able to present a comprehensive and detailed statement of the patient's present illness or problems, edited according to the 480

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PROBLEMS,

Objectives: (A) To identify and list separately active and inactive problems; (B) to take the patient's past history and family history; (C) system review (including obstetric-gynecologic history). By the end of Stage IX, we expect the student to be familiar with the general technique of history taking and recording and with the physical examination. He should be capable of communicating with the patient in an understanding, sympathetic, and professional manner. The remaining training sessions are devoted to improving students' performance in history taking and physical examination, refining their knowledge and use of the medical vocabulary, and familiarizing them with physical findings, with a growing emphasis on diagnostic problem solving. Students now have to present a complete case history and a comprehensive report of physical findings followed by a list of (A) significant symptoms and signs; (B) provisional diagnoses (or differential diagnosis); (C) symptoms and signs (if any) not accounted by the proposed diagnoses; (D) suggestions for clinical investigation. The evaluation of students' progress is built into the training program. Repeated problem-solving exercises, role playing, and other simulation devices are used for both training and evaluation. Students' performances and their observed behaviors toward patients and peers during the course appeared to be closer to those of experienced physicians.

STATEMENT OF THE PATIENT'S PRESENT

PROBLEM ( S )

STAGE VII.

LISTING ACTIVE AND INACTIVE

PAST AND FAMILY HISTORY, SYSTEM REVIEW

4

come their initial inhibitions and natural reluctance to invade other people's privacy. The time allotted to such an introductory phase should be sufficiently flexible so that it can meet the needs of individual students. After they are more confident about approaching patients, the students are introduced to the techniques of the structured patient interview and to history taking. A relatively large part of the instruction time is devoted to practical exercises in identifying, listing, and describing patients' "positive" and "negative" symptoms. We oppose the traditional approach of "stick to the patient's own words" because it is often misinterpreted by students who then record the patient's entire narrative without making any attempt to discriminate between relevant and irrelevant data. According to our approach, students should be encouraged to use their own judgment in determining the relative significance of the data obtained and to record them in the order of their relative importance, using the problem oriented approach and format. The problem-oriented approach in teaching the introduction to clinical medicine may, of course, lead to "overfragmentation" of the medical history by the inexperienced student. He may not recognize the connection between the swollen calf and the sudden pain in the chest and may see these complaints as two distinct problems. Nevertheless, identification, categorization, and meticulous description of various groups of symptoms, and a programmed selection of patients presenting problems of increasing complexity are basic tenets of our course because they constitute a foundation for the desired clinical approach. Rather than expecting the student to gradually improve his technique of taking and recording the complete case history through repeated practice, our method is based on the principle of "learning for mastery" (5). Students are asked to concentrate on and record one single aspect of the case history, and are not allowed to proceed to the next stage before they have mastered the previous one. As students progress from stage to stage, and, as they learn to accumulate a larger number and more specific history data, they are also expected to progress from initial diagnoses based on anatomic location only to more specific diagnostic hypotheses. We reject the traditional warning "don't jump to conclusions" because it, too, is often misinterpreted by students as suggesting that the case history should be taken and recorded passively, rather than through an active and per-

sistent search for cues guided by early, provisional diagnostic hypotheses. We realize that the early diagnostic hypotheses generated by students tend to be general. However, even nonspecific, provisional hypotheses, though they may have to be rejected during subsequent stages of the diagnostic process, stimulate further probing and a more meaningful interview and physical examination. The strategies used by expert physicians, although more efficient are not basically different. One of the outgrowths of the scientific reform has been a tendency to emphasize the acquisition of subject matter competence in the basic sciences before the introduction to clinical medicine and the teaching of the strategies used by expert physicians in diagnostic problem solving. Indeed, mastery of subject matter and a high degree of associative fluency characterize the superior performance of the experienced physician as compared to that of the inexperienced student. We feel that systematic teaching of nosologic entities only prior to, and as a basis for, clinical reasoning creates an unnecessary delay, and may even hinder the development of problem-solving skills. Our pilot experiment indicates that it is possible to teach medical students early in their education, even before they have acquired the necessary subject matter competence, to use diagnostic strategies similar to those of experienced physicians. An evaluation model including clinical sequential simulations specially designed for the course objectives, is now being developed for implementation in the coming academic year. ACKNOWLEDGMENT: The authors are grateful to Miss L. Karp for her help in the preparation of the manuscript. Received 19 December 1975; revision accepted 12 January 1976. • Requests for reprints should be addressed to J. Benbassat, M.D., Department of Medicine A, Hadassah University Hospital, P.O. Box 499, Jerusalem, Israel. References 1. MORGAN WL, ENGEL GL (eds): The Clinical Approach to the

Patient. Philadelphia, W. B. Saunders Co. 1969 2. BOMFORD E, MASON S, SWASH M (eds): Hutchinson's Clinical

Methods. London, Baillere Tindall, 1975 3. ELSTEIN AS, KAGAN N, SHULMAN LS: Methods and theory in

the study of medical inquiry. / Med Educ 47:85-92, 1972 4. WEED LL: Medical Records, Medical Education and Patient Care. Cleveland, The Press of Western Reserve University, 1969 5. BLOOM BS, HASTINGS JT, MADAUS GF: Learning for mastery,

in Handbook on Formative and Summative Evaluation of Student Learning. New York, McGraw Hill Book Co., 1971, pp. 43-57 6. LIBKE A, YARNALL S, FUNK D, et al: An Introduction to the

Medical History and the Medical Record, 3rd ed. Seattle, University of Washington School of Medicine, 1972

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An approach to teaching the introduction to clinical medicine.

An approach to teaching the introduction of clinical medicine to medical students is described. It is based on (A) gradual exposure to patients and st...
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