556
Medical Education
HISTORY-TAKING FOR MEDICAL STUDENTS I—DEFICIENCIES IN PERFORMANCE G. P. MAGUIRE
University Department of Psychiatry, University Hospital of South Manchester, West Didsbury, Manchester M20 8LR D. R. RUTTER
Department of Psychology, University of Warwick, Coventry CV4 7AL
videotape analysis of histories conby 50 senior medical students was carried out to assess their history-taking skills. As predicted, serious deficiencies (similar to those evident in inexperienced medical students) were found. It is argued that traditional methods of clinical training fail to equip medical students with adequate history-taking skills. They should be given a more appropriate history-taking scheme, the opportunity to practise this under conditions of direct observation within strict time-limits, and detailed feedback about their performance.
Summary
A
ducted
INTRODUCTION
THE initial history is a fundamental aspect of clinical practice.’ It is, therefore, essential that doctors are equipped with the skills required to elicit information that is both accurate and relevant to an understanding of their patients’ problems. It is also crucial that they learn to establish effective relationships with their patients. However, studies which have monitored directly the performances of medical students with general medical and surgical patients, suggest that students lack basic history-taking skills.23 These deficiencies include an inability to keep patients to the point and to clarify the real nature of patients’ complaints, reluctance to ask about relevant psychological and social aspects of their histories, and failure to pick up important verbal and
non-verbal
cues.
These studies have been carried out with inexperienced students, and it is possible to argue that their further clinical training makes good- these deficiencies. However, given the nature of the difficulties and the methods traditionally used to teach history-taking, we considered it much more likely that such improvements do not occur. We hypothesised, therefore, that senior medical students would display the same deficiencies in their history-taking skills. We sought to test this by a detailed analysis of histories conducted by a series of senior medical students. METHODS
50 medical students in the University of Oxford who doing a clerkship in psychiatry were consecutively included, provided that they were within 15 months of their final examinations and had completed firms in were
medicine, surgery, paediatrics, and obstetrics and gynæcology. The students were each asked to interview a psychiatric patient previously unknown to them. They were told that they had 15 minutes to determine the patient’s present problems and that it was their responsibility to end their interviews on time. Students were also informed that the purpose of the exercise was to assess their history-taking skills, and that they should write up a careful history afterwards. Finally, they were given their patients’ names and told that they should assume that their patients were ignorant about the task in hand, The exercise was designed to test basic history-taking skills only. Patients were, therefore, selected as follows : they were recovering from a depressive illness or anxiety state, were very willing to cooperate, and were able to give a good and coherent history within the time. Each interview was recorded on videotape. The recordings were then analysed to find out the extent to which the students displayed skills in history-taking. This was done by means of a rating scale specially developed for the purpose.4 Where the technique was discrete, such as a student explaining who he was, it was simply rated as present (1) or absent (0). When the technique was complex, for example "helping the patient keep to the point", a 5-point scale from 0-4 was used. A score of 0 meant that the student was "very poor", allowing the patient to spend all the time talking of matters quite irrelevant to the task in hand. A score of 4 meant that the student encouraged the patient to be relevant throughout the interview and so was rated as "very good". The written histories were analysed in terms of the number of items of accurate and relevant information which they con tained. Judgments of relevance were based on the
patients’ case-notes. RESULTS
Amount of Data Elicited
particularly worrying to find that 24% of the students failed to discover their patient’s main problems, In all, the students reported a median of only 14 items of information in their histories. This represented just onethird of the data which were readily obtainable in the time allowed. The students reported virtually no data about the effects the psychiatric illness had had on the patients’ marriages, sexual adjustment, or day-to-day functioning, or about what supports, if any, they had had. When these results were fed back to the students they were surpriscd; they had all considered themselves very much more efficient at gathering information. It
was
Deficiencies in Technique When beginning their interviews, most students (78%) gave clear greetings to the patients and address them by their correct names (88%). Slightly fewer (70% indicated verbally or by gesture where the patient should sit. Although they were meeting these patient for the first time, 30% of students did not introduce. themselves by name, 44% failed to mention they were medical students, and 68% neglected to explain the firm’ to which they were attached. Only 16% of students bothered to check that their patients understood that their,terviews were being recorded and filmed and that this
557
acceptable. Even fewer students (4%) gave any indiof the time they had or the fact that they would like to take notes, or checked that the patient was at ease, Only 8% explained the purpose of their interviews. was
cation
The students were rated on 10 items for their performance in taking the main history, and the results are shown in the accompanying table. RATINGS OF HISTORY-TAKING
questions in a form which led their patients to answer in a particular way. For example, they would ask, "you were waking up early?" rather than, "did you notice any change in your sleeping habits?". 24% made their questions so complicated and lengthy that it was impossible for the patients to recall the separate elements or give appropriate answers. (10) Other difficulties.-We noted that most students assumed that there would only be one illness or problem. They on the first complaint volunteered and did not bother to check whether there could be others of equal or greater importance. They then adopted a mode of history-taking oriented either to physical or to psychiatric illness. They did not seem able to cope with the possibility that both might be present. Whichever scheme they followed, they found it difficult to tailor it to the task they had been given.
usually seized
TECHNIQUES
Only 10% of the students ended their interviews in the time. Even fewer (8%) attempted to check that they had got the history right before they finished. DISCUSSION
analysis revealed serious deficiencies in the tory-taking skills of these senior medical students, Our
(1) Avoidance of more personal issues.-36% of students avoided asking any specific questions or responding to any cues about their patients’ personal relationships, sexual adjustment, or feelings about their illnesses. They also neglected to check whether or not their patients had felt suicidal. A further 44% touched on these matters only very superficially, their patients had volunteered them as problems.
even
though
(2) Acceptance of jargon.-When patients used phrases such as "feeling run down", "depressed", or "tense" to describe their complaints, only 8% of students attempted routinely to establish what they really meant. 78% of students simply took such statements at face value. In consequence, several of them were seriously misled about the true nature of their patients’ problems. (3) Imprecision.-The majority of students (86%) made little effort to date the key events in their patients’ histories precisely or to determine the names, duration, dosages, and effects of any treatments which had been prescribed. (4) Failure to pick up verbal leads.-All the patients provided many useful verbal cues about the nature of their problems, Henceit was disconcerting that 74% of the students failed to pick up more than a fraction of these. Only 4% of students were able consistently to detect and use the cues given to them. Patients were often forced to repeat key phrases such as "I was feeling very low" as many as ten times in order to try to get the students to acknowledge their mood disturbance. (5) Repetition.-It would be some comfort if the low amount of information obtained could be attributed to the time-limits imposed. However, this claim is difficult to sustain given the finding that 72% of students lost much time through needlessly repeating topics already well covered. (6) Lack of clarification.--62% of students failed to confront patients with the marked inconsistencies or gaps in their stories. The information elicited was frequently confused and conflicting. Only 8% obtained a "good" or "very good" rating on this item. (7) Lack of control.-Over half the students (54%) allowed their patients to talk abcut irrelevant matters without making any but the most hesitant attempts to interrupt them and bring them back to the point. Yet where 5 other students made consistent attempts to keep their patients to the point the patients were eager to cooperate. 8 Facilitation.—The students experienced much less difficulty in encouraging their patients to talk. Even so, 32% gave little or no indication that they wanted their patients to continue talking. Instead, they often buried their heads in their notes and rarely, if ever, looked at their patients. 9 Inappropriate question style.-34% of students put
hisand those
confirmed that the deficiencies are identical to found in less experienced medical students. However, since these deficiencies were revealed in a test situation, it could be argued that they represent a response to our particular task rather than the students’ true historytaking abilities. We arranged, therefore, for audiotape recordings to be made of 12 of these students while they were taking histories from new outpatients. Comparison of these histories with those taken in the test showed identical deficiencies in technique. We thus think it reasonable to conclude that these deficiencies are real, particularly as the students readily acknowledged them. Support for this view comes from the work of Helfer.s He found that senior medical students were much more likely than inexperienced students to ask leading questions, avoid emotional aspects of cases, use medical jargon, and
ignore important cues. Furthermore, when medical students are asked what difficulties they have when talking to patients they describe exactly similar problems to those we found.6 If our findings are valid, similar deficiencies should be evident in qualified doctors who have received the same type of training. Studies of the practice of physicians,’paediatricians,8 surgeons,9 and general practitioners’° confirm this. While the nature and magnitude of these deficiencies may be depressing, they should not be surprising. Little time is yet devoted in most medical school curricula to formal training in history-taking skills. The time that is given is usually taken up with a few seminars and demonstrations which focus on the questions which should be asked to elicit physical illness. Little guidance is given about the techniques which should be used or about coverage of the psychological and social aspects of each case. Thereafter, a student’s learning is generally based on his tutor’s appraisal of the histories which he reports back in seminars or on ward-rounds. Little attention is likely to be paid to how the student obtained his data or related to his patient. It is also most unlikely that the tutor will have actually observed his student taking a history. A further problem arises from the history-taking schemes which the student is given by various departments. These are likely to be fragmented and conflict-
558
ing, and so make it difficult for the student to develop the holistic approach which he will need to adopt if he is to meet the needs of his patients and overcome the constraints of limited time which he will meet in real practice. It seems probable, therefore, that the history-taking skills of medical students could be much improved if these gaps in training were remedied. We suggest that this could be done as follows: by giving students a more detailed and relevant model of how to take an initial history and what questions to ask; by giving them a chance to practise this under conditions of direct observation within strict time-limits; and by providing them with feedback about their performance. Indeed, we have already put these suggestions to the test, and, as we report in the following paper" and in a recent review,12 the results have been encouraging. They indicate that much could be done of a practical nature to help medical students and doctors to improve their history-taking skills, particularly if such training were given at the beginning of their clinical course, or even
pre-clinically. 13I
This work was carried out while both authors were in the departof psychiatry, University of Oxford. D. R. R. was supported by the Mental Health Trust and Research Fund and by the Medical Research Council. We thank Prof. Michael Gelderfor his encouragement and the patients for their cooperation.
who received only traditional training. Results of the second experiment suggest that most of the programme’s effect is attributable to discussion of a printed handout which presents the student with a detailed scheme for taking histories. INTRODUCTION
preceding paper,’ we drew attention to a growing body of evidence which suggests that traditional methods of clinical training are failing to equip doctors with basic skills for taking patients’ histories. We have developed our own training programmes,2 and have tested its value in two experiments. The first tested the IN the
programme as a whole, and the second assessed the relative importance of its separate components. FIRST EXPERIMENT
The first experiment tested the hypothesis that the amount of relevant and accurate information reported at the end of a test interview would be greater for students trained by our programme than for those trained
by traditional methods.
ment
REFERENCES
1.
Hampton, J. R., Harris, M. J. G., Mitchell, J. R. A., Prichard, J. S., Seymour, C. Br. med. J. 1975, ii, 486. 2. Anderson, J., Day, J. L., Dowling, M. A. C., Pettingale, K. W. Post-Grad. med. J. 1970, 46, 606. 3. Tapia, F. Br. J. med. Educ. 1972, 6, 133. 4. Maguire, G. P., Clarke, D., Jolley, B., Unpublished. 5. Helfer, R. E. Pediatrics, Springfield, 1970, 45, 623. 6. MacNamara, M. Br. J. med. Educ. 1974, 8, 17. 7. Maguire, G. P., Julier, D. L., Hawton, K. E., Bancroft, J. H. J. Br. med. J. 1974, i, 286. 8. Korsch, B. M., Gozzi, E. K., Francis, V. Pediatrics, Springfield, 1968, 42, 855.
Maguire, G. P. in Modern Perspectives in Psychiatric Aspects of Surgery (edited by J. Howells and M. Bruner); New York (in the press). 10. Goldberg, D. P., Blackwell, B. Br. med. J. 1970, ii, 439. 11. Rutter, D. R., Maguire, G. P. Lancet, 1976, ii, 558. 12. Maguire, G. P., Rutter, D. R. in Communication between Doctors and Patients (edited by A. E., Bennett); p.45. Oxford, 1976. 13. British Medical Journal, 1976, i, 1362. 9.
HISTORY-TAKING FOR MEDICAL STUDENTS II—EVALUATION OF A TRAINING PROGRAMME
D. R. RUTTER
Department of Psychology, University of Warwick, Coventry CV4 7AL
Subjects and Procedure A consecutive sample of 24 medical students took part in the experiment during their first psychiatric attachment. All had already received a traditional training in taking histories. 12 were randomly allocated to a "training" group, and 12 to a "no-training" group, and each student conducted two videotaped interviews which were separated by a week. On each occasion, the student was set the task of spending 15 minutes with the patient and of finding out as much as he could about the current illness or problems. He was told that the patient was suffering from an affective disorder, that the interview would be videotaped, that it was his responsibility to terminate the interview on time, and that he would be asked to write up the patient’s history immediately afterwards. The patients-inpatients, day-patients, or outpatients-were suffering from clearly diagnosed affective disorders, and were selected by medical staff not otherwise connected with the experiment. Each student met a different patient on the two occasions, and each patient took part in only one interview. Having written up the patient’s history at the end of the first interview, students assigned to the no-training group were sent allay without comment, and were asked to return the following week for the second interview and not to discuss the experiment in the meantime. Those assigned to the training group remained and were given their training, individually, by G.P.M. One week later, all 24 students returned for their second interviews and, after they had written up the patient’s history, they were debriefed,
G. P. MAGUIRE
University Department of Psychiatry, University Hospital of South Manchester, West Didsbury, Manchester M20 8LR
Training Details of the
training
programme have been giver a printed handed
elsewhere.2 First, the student is given
sets out a standard, structured scheme for taking histories, and draws attention both to the informaticr
which Two experiments designed to evaluate a Summary programme for training medical students in history-taking skills were carried out. Results of the first indicate that students who underwent the programme reported almost three times as much relevant and accurate information after a test interview as those
which should be obtained and to the techniques v.h). should be used. He reads the handout carefully and d.i cusses it with the trainer. Next, his interview is reptaBei The recording can be stopped and replayed again at jr point, and the student’s performance is discussedr:
Medical Education
HISTORY-TAKING FOR MEDICAL STUDENTS I—DEFICIENCIES IN PERFORMANCE G. P. MAGUIRE
University Department of Psychiatry, University Hospital of South Manchester, West Didsbury, Manchester M20 8LR D. R. RUTTER
Department of Psychology, University of Warwick, Coventry CV4 7AL
videotape analysis of histories conby 50 senior medical students was carried out to assess their history-taking skills. As predicted, serious deficiencies (similar to those evident in inexperienced medical students) were found. It is argued that traditional methods of clinical training fail to equip medical students with adequate history-taking skills. They should be given a more appropriate history-taking scheme, the opportunity to practise this under conditions of direct observation within strict time-limits, and detailed feedback about their performance.
Summary
A
ducted
INTRODUCTION
THE initial history is a fundamental aspect of clinical practice.’ It is, therefore, essential that doctors are equipped with the skills required to elicit information that is both accurate and relevant to an understanding of their patients’ problems. It is also crucial that they learn to establish effective relationships with their patients. However, studies which have monitored directly the performances of medical students with general medical and surgical patients, suggest that students lack basic history-taking skills.23 These deficiencies include an inability to keep patients to the point and to clarify the real nature of patients’ complaints, reluctance to ask about relevant psychological and social aspects of their histories, and failure to pick up important verbal and
non-verbal
cues.
These studies have been carried out with inexperienced students, and it is possible to argue that their further clinical training makes good- these deficiencies. However, given the nature of the difficulties and the methods traditionally used to teach history-taking, we considered it much more likely that such improvements do not occur. We hypothesised, therefore, that senior medical students would display the same deficiencies in their history-taking skills. We sought to test this by a detailed analysis of histories conducted by a series of senior medical students. METHODS
50 medical students in the University of Oxford who doing a clerkship in psychiatry were consecutively included, provided that they were within 15 months of their final examinations and had completed firms in were
medicine, surgery, paediatrics, and obstetrics and gynæcology. The students were each asked to interview a psychiatric patient previously unknown to them. They were told that they had 15 minutes to determine the patient’s present problems and that it was their responsibility to end their interviews on time. Students were also informed that the purpose of the exercise was to assess their history-taking skills, and that they should write up a careful history afterwards. Finally, they were given their patients’ names and told that they should assume that their patients were ignorant about the task in hand, The exercise was designed to test basic history-taking skills only. Patients were, therefore, selected as follows : they were recovering from a depressive illness or anxiety state, were very willing to cooperate, and were able to give a good and coherent history within the time. Each interview was recorded on videotape. The recordings were then analysed to find out the extent to which the students displayed skills in history-taking. This was done by means of a rating scale specially developed for the purpose.4 Where the technique was discrete, such as a student explaining who he was, it was simply rated as present (1) or absent (0). When the technique was complex, for example "helping the patient keep to the point", a 5-point scale from 0-4 was used. A score of 0 meant that the student was "very poor", allowing the patient to spend all the time talking of matters quite irrelevant to the task in hand. A score of 4 meant that the student encouraged the patient to be relevant throughout the interview and so was rated as "very good". The written histories were analysed in terms of the number of items of accurate and relevant information which they con tained. Judgments of relevance were based on the
patients’ case-notes. RESULTS
Amount of Data Elicited
particularly worrying to find that 24% of the students failed to discover their patient’s main problems, In all, the students reported a median of only 14 items of information in their histories. This represented just onethird of the data which were readily obtainable in the time allowed. The students reported virtually no data about the effects the psychiatric illness had had on the patients’ marriages, sexual adjustment, or day-to-day functioning, or about what supports, if any, they had had. When these results were fed back to the students they were surpriscd; they had all considered themselves very much more efficient at gathering information. It
was
Deficiencies in Technique When beginning their interviews, most students (78%) gave clear greetings to the patients and address them by their correct names (88%). Slightly fewer (70% indicated verbally or by gesture where the patient should sit. Although they were meeting these patient for the first time, 30% of students did not introduce. themselves by name, 44% failed to mention they were medical students, and 68% neglected to explain the firm’ to which they were attached. Only 16% of students bothered to check that their patients understood that their,terviews were being recorded and filmed and that this
557
acceptable. Even fewer students (4%) gave any indiof the time they had or the fact that they would like to take notes, or checked that the patient was at ease, Only 8% explained the purpose of their interviews. was
cation
The students were rated on 10 items for their performance in taking the main history, and the results are shown in the accompanying table. RATINGS OF HISTORY-TAKING
questions in a form which led their patients to answer in a particular way. For example, they would ask, "you were waking up early?" rather than, "did you notice any change in your sleeping habits?". 24% made their questions so complicated and lengthy that it was impossible for the patients to recall the separate elements or give appropriate answers. (10) Other difficulties.-We noted that most students assumed that there would only be one illness or problem. They on the first complaint volunteered and did not bother to check whether there could be others of equal or greater importance. They then adopted a mode of history-taking oriented either to physical or to psychiatric illness. They did not seem able to cope with the possibility that both might be present. Whichever scheme they followed, they found it difficult to tailor it to the task they had been given.
usually seized
TECHNIQUES
Only 10% of the students ended their interviews in the time. Even fewer (8%) attempted to check that they had got the history right before they finished. DISCUSSION
analysis revealed serious deficiencies in the tory-taking skills of these senior medical students, Our
(1) Avoidance of more personal issues.-36% of students avoided asking any specific questions or responding to any cues about their patients’ personal relationships, sexual adjustment, or feelings about their illnesses. They also neglected to check whether or not their patients had felt suicidal. A further 44% touched on these matters only very superficially, their patients had volunteered them as problems.
even
though
(2) Acceptance of jargon.-When patients used phrases such as "feeling run down", "depressed", or "tense" to describe their complaints, only 8% of students attempted routinely to establish what they really meant. 78% of students simply took such statements at face value. In consequence, several of them were seriously misled about the true nature of their patients’ problems. (3) Imprecision.-The majority of students (86%) made little effort to date the key events in their patients’ histories precisely or to determine the names, duration, dosages, and effects of any treatments which had been prescribed. (4) Failure to pick up verbal leads.-All the patients provided many useful verbal cues about the nature of their problems, Henceit was disconcerting that 74% of the students failed to pick up more than a fraction of these. Only 4% of students were able consistently to detect and use the cues given to them. Patients were often forced to repeat key phrases such as "I was feeling very low" as many as ten times in order to try to get the students to acknowledge their mood disturbance. (5) Repetition.-It would be some comfort if the low amount of information obtained could be attributed to the time-limits imposed. However, this claim is difficult to sustain given the finding that 72% of students lost much time through needlessly repeating topics already well covered. (6) Lack of clarification.--62% of students failed to confront patients with the marked inconsistencies or gaps in their stories. The information elicited was frequently confused and conflicting. Only 8% obtained a "good" or "very good" rating on this item. (7) Lack of control.-Over half the students (54%) allowed their patients to talk abcut irrelevant matters without making any but the most hesitant attempts to interrupt them and bring them back to the point. Yet where 5 other students made consistent attempts to keep their patients to the point the patients were eager to cooperate. 8 Facilitation.—The students experienced much less difficulty in encouraging their patients to talk. Even so, 32% gave little or no indication that they wanted their patients to continue talking. Instead, they often buried their heads in their notes and rarely, if ever, looked at their patients. 9 Inappropriate question style.-34% of students put
hisand those
confirmed that the deficiencies are identical to found in less experienced medical students. However, since these deficiencies were revealed in a test situation, it could be argued that they represent a response to our particular task rather than the students’ true historytaking abilities. We arranged, therefore, for audiotape recordings to be made of 12 of these students while they were taking histories from new outpatients. Comparison of these histories with those taken in the test showed identical deficiencies in technique. We thus think it reasonable to conclude that these deficiencies are real, particularly as the students readily acknowledged them. Support for this view comes from the work of Helfer.s He found that senior medical students were much more likely than inexperienced students to ask leading questions, avoid emotional aspects of cases, use medical jargon, and
ignore important cues. Furthermore, when medical students are asked what difficulties they have when talking to patients they describe exactly similar problems to those we found.6 If our findings are valid, similar deficiencies should be evident in qualified doctors who have received the same type of training. Studies of the practice of physicians,’paediatricians,8 surgeons,9 and general practitioners’° confirm this. While the nature and magnitude of these deficiencies may be depressing, they should not be surprising. Little time is yet devoted in most medical school curricula to formal training in history-taking skills. The time that is given is usually taken up with a few seminars and demonstrations which focus on the questions which should be asked to elicit physical illness. Little guidance is given about the techniques which should be used or about coverage of the psychological and social aspects of each case. Thereafter, a student’s learning is generally based on his tutor’s appraisal of the histories which he reports back in seminars or on ward-rounds. Little attention is likely to be paid to how the student obtained his data or related to his patient. It is also most unlikely that the tutor will have actually observed his student taking a history. A further problem arises from the history-taking schemes which the student is given by various departments. These are likely to be fragmented and conflict-
558
ing, and so make it difficult for the student to develop the holistic approach which he will need to adopt if he is to meet the needs of his patients and overcome the constraints of limited time which he will meet in real practice. It seems probable, therefore, that the history-taking skills of medical students could be much improved if these gaps in training were remedied. We suggest that this could be done as follows: by giving students a more detailed and relevant model of how to take an initial history and what questions to ask; by giving them a chance to practise this under conditions of direct observation within strict time-limits; and by providing them with feedback about their performance. Indeed, we have already put these suggestions to the test, and, as we report in the following paper" and in a recent review,12 the results have been encouraging. They indicate that much could be done of a practical nature to help medical students and doctors to improve their history-taking skills, particularly if such training were given at the beginning of their clinical course, or even
pre-clinically. 13I
This work was carried out while both authors were in the departof psychiatry, University of Oxford. D. R. R. was supported by the Mental Health Trust and Research Fund and by the Medical Research Council. We thank Prof. Michael Gelderfor his encouragement and the patients for their cooperation.
who received only traditional training. Results of the second experiment suggest that most of the programme’s effect is attributable to discussion of a printed handout which presents the student with a detailed scheme for taking histories. INTRODUCTION
preceding paper,’ we drew attention to a growing body of evidence which suggests that traditional methods of clinical training are failing to equip doctors with basic skills for taking patients’ histories. We have developed our own training programmes,2 and have tested its value in two experiments. The first tested the IN the
programme as a whole, and the second assessed the relative importance of its separate components. FIRST EXPERIMENT
The first experiment tested the hypothesis that the amount of relevant and accurate information reported at the end of a test interview would be greater for students trained by our programme than for those trained
by traditional methods.
ment
REFERENCES
1.
Hampton, J. R., Harris, M. J. G., Mitchell, J. R. A., Prichard, J. S., Seymour, C. Br. med. J. 1975, ii, 486. 2. Anderson, J., Day, J. L., Dowling, M. A. C., Pettingale, K. W. Post-Grad. med. J. 1970, 46, 606. 3. Tapia, F. Br. J. med. Educ. 1972, 6, 133. 4. Maguire, G. P., Clarke, D., Jolley, B., Unpublished. 5. Helfer, R. E. Pediatrics, Springfield, 1970, 45, 623. 6. MacNamara, M. Br. J. med. Educ. 1974, 8, 17. 7. Maguire, G. P., Julier, D. L., Hawton, K. E., Bancroft, J. H. J. Br. med. J. 1974, i, 286. 8. Korsch, B. M., Gozzi, E. K., Francis, V. Pediatrics, Springfield, 1968, 42, 855.
Maguire, G. P. in Modern Perspectives in Psychiatric Aspects of Surgery (edited by J. Howells and M. Bruner); New York (in the press). 10. Goldberg, D. P., Blackwell, B. Br. med. J. 1970, ii, 439. 11. Rutter, D. R., Maguire, G. P. Lancet, 1976, ii, 558. 12. Maguire, G. P., Rutter, D. R. in Communication between Doctors and Patients (edited by A. E., Bennett); p.45. Oxford, 1976. 13. British Medical Journal, 1976, i, 1362. 9.
HISTORY-TAKING FOR MEDICAL STUDENTS II—EVALUATION OF A TRAINING PROGRAMME
D. R. RUTTER
Department of Psychology, University of Warwick, Coventry CV4 7AL
Subjects and Procedure A consecutive sample of 24 medical students took part in the experiment during their first psychiatric attachment. All had already received a traditional training in taking histories. 12 were randomly allocated to a "training" group, and 12 to a "no-training" group, and each student conducted two videotaped interviews which were separated by a week. On each occasion, the student was set the task of spending 15 minutes with the patient and of finding out as much as he could about the current illness or problems. He was told that the patient was suffering from an affective disorder, that the interview would be videotaped, that it was his responsibility to terminate the interview on time, and that he would be asked to write up the patient’s history immediately afterwards. The patients-inpatients, day-patients, or outpatients-were suffering from clearly diagnosed affective disorders, and were selected by medical staff not otherwise connected with the experiment. Each student met a different patient on the two occasions, and each patient took part in only one interview. Having written up the patient’s history at the end of the first interview, students assigned to the no-training group were sent allay without comment, and were asked to return the following week for the second interview and not to discuss the experiment in the meantime. Those assigned to the training group remained and were given their training, individually, by G.P.M. One week later, all 24 students returned for their second interviews and, after they had written up the patient’s history, they were debriefed,
G. P. MAGUIRE
University Department of Psychiatry, University Hospital of South Manchester, West Didsbury, Manchester M20 8LR
Training Details of the
training
programme have been giver a printed handed
elsewhere.2 First, the student is given
sets out a standard, structured scheme for taking histories, and draws attention both to the informaticr
which Two experiments designed to evaluate a Summary programme for training medical students in history-taking skills were carried out. Results of the first indicate that students who underwent the programme reported almost three times as much relevant and accurate information after a test interview as those
which should be obtained and to the techniques v.h). should be used. He reads the handout carefully and d.i cusses it with the trainer. Next, his interview is reptaBei The recording can be stopped and replayed again at jr point, and the student’s performance is discussedr:
