Teaching Clinical Medicine by Iterative Hypothesis Testing

Kassirer, Jerome P.

doi:10.1056/nejm198310133091511

Cited by 131 publications

(60 citation statements)

References 11 publications

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“…For the purpose of this report, we use the term 'hypothesis-driven' to include skills of gathering information in an iterative process during the H&P, using clinical problem solving and hypothesis testing (Kassirer, 1983). We identified four H&P functions as particularly relevant to performing hypothesis-driven H&P: (3) pertinent history elements, (4) focused histories, (7) clinical reasoning, and (10) focused physicals (see Table 2).…”

Section: Hypothesis-driven Handp: Learned Predominantly In Implicit Curmentioning

confidence: 99%

Impact of Explicit, Implicit, and Extra Curricula on Students’ Learning of the History and Physical Examination

Tucker¹,

Balmer²,

Gowda³

2017

MedEdPublish

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Purpose: History taking and physical examination (H&P) in a patient-centered manner is central to the practice of medicine. This qualitative case study explored the relative influences of explicit, implicit, and extra curricula on medical students' learning of the H&P. Methods:The authors conducted semi-structured interviews with 15 fourth-year medical students at Columbia University from September 2015 to January 2016. The authors coded interview transcripts in an iterative process, and clustered coded data into emerging themes to elucidate how curricula shaped students' learning of the H&P.Results: Students perceived misalignment between curricula, with two predominant patterns: lesser emphasis on patient-centered H&P and greater emphasis on hypothesis-driven H&P in implicit versus explicit curricula. Role models, patient interactions, and clinical context were important influences on students' learning of patient-centered H&P. Ward rounds, role models, and feedback were particularly impactful for students' learning of hypothesis-driven H&P. Students reported minimal learning from the extra curriculum.Conclusions: Medical students perceived a misalignment in learning the H&P between the explicit and implicit curricula, with the former being primarily where students developed patient-centeredness in conducting H&Ps and the latter being where students learned to conduct hypothesis-driven H&P. Efforts to align curricula could strengthen H&P training.

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Section: Hypothesis-driven Handp: Learned Predominantly In Implicit Curmentioning

confidence: 99%

Impact of Explicit, Implicit, and Extra Curricula on Students’ Learning of the History and Physical Examination

Tucker¹,

Balmer²,

Gowda³

2017

MedEdPublish

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“…Several reports have shown that the medical history obtained during the medical interview provides 60-80% of the information needed for an accurate diagnosis (Hampton et al 1975;Sandler 1980;Kassirer 1983;Peterson 1992). Numerous medical interview behaviors can be used to gather medical information from patients, including open-ended questions (Rutter and Cox 1981;Cox et al 1981a, b;Beckman and Frankel 1984;Roter and Hall 1987;Maguire et al 1996;Marvel et al 1999;Takemura et al 2004), facilitation (Rogers 1980;Egan 1990;Wissow 1994), the open-to-closed cone (Cox et al 1981a; Bird and Cohen-Cole adjustment was made in this study to eliminate its effects.…”

confidence: 99%

Identifying Medical Interview Behaviors that Best Elicit Information from Patients in Clinical Practice

Takemura

Atsumi

Tsuda

2007

Tohoku J. Exp. Med.

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Many textbooks indicate the desirability of using specific medical interview behaviors to obtain information from patients, although little evidence has been presented. The aim of this study is to investigate the relationships between the use of medical interview behaviors and the amount of information obtained. The behaviors studied included: open-ended questions, facilitation (comments or interviewer behavior that encourages the patient to continue talking), the open-to-closed cone (the gradual narrowing of focus from an initial nondirective approach to a more direct exploration), summarization (providing the patient with an explicit verbal summary of the information gathered thus far), and surveying problems. The subjects were 315 patients who visited an outpatient facility. These medical interviews were videotaped and reviewed by a trained rater using the Takemura Medical Interview Rating Scale, which was developed to assess the use of particular medical interview behaviors and to measure the amount of information obtained from patients regarding their chief physical complaints. Significant positive relationships were found between three particular interview behaviors and the amount of information obtained: facilitation, the open-to-closed cone, and summarization. These positive relationships were still present after adjusting for other medical interview behaviors used, and after adjusting for the time duration of the medical interviews (F = 15.3, p < 0.0001; F = 40.1, p < 0.0001; F = 5.57, p = 0.019, respectedly). This study reveals a positive relationship between three specific medical interview behaviors (facilitation, the open-to-closed cone, and summarization) and the amount of information obtained in a real clinical practice setting.

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“…This information, along with the findings on physical examination, are then synthesized to form a problem list from which a differential diagnosis or diagnoses can be made. Research dating back to the 1970's suggests that patient history alone can yield a diagnosis in 76% of cases [1] and, otherwise, can contribute up to 80% of the information required to make a diagnosis [1][2][3][4][5]. More recent studies point to the additional benefits of patient rapport, better patient health literacy, therapeutic compliance, and clinical outcomes [6][7][8][9].…”

Section: Introductionmentioning

confidence: 99%

Thoughtful questions in the history as new pedagogy for teaching patient centred care: A pilot study in an Australian Rural Clinical School (RCS).

Middleton¹,

Buist²

2018

J Contemp Med Edu

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Introduction:The taking of the patient medical history is at the heart of the doctor patient relationship. It is often critical for a diagnosis and also plays an important part in ongoing clinical care of the patient. However, with the move away from assessment by "long case" to the Objective Structured Clinical Examination (OSCE), medical students spend less time with patients and when they do take a history it is done in a didactic checklist manner. This learning is contrary to the needs of the now more health literate patient. Methods: By an iterative process, we developed a program of teaching medical history at the bedside of real patients that focussed on listening to what the patient said as opposed to the traditional history checklist. By anonymous online survey we sought feedback from the students on this way teaching. Results: Over the 3 years of this program (from 2013) 76 of the 85 students responded to the survey (89% response rate). Students were mostly receptive to the ideas of following up on clues and information that patients gave them and then presenting this information in a more interesting way to peers. However, there was less enthusiasm, for taking the history in a more casual but patient centred way. Conclusion: This program was feasible and welcomed by the students. The major limitations were that students were frustrated by not being taught examinable OSCE cases and that the time commitment by the clinician was onerous.

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Teaching Clinical Medicine by Iterative Hypothesis Testing

Cited by 131 publications

References 11 publications

Impact of Explicit, Implicit, and Extra Curricula on Students’ Learning of the History and Physical Examination

Impact of Explicit, Implicit, and Extra Curricula on Students’ Learning of the History and Physical Examination

Identifying Medical Interview Behaviors that Best Elicit Information from Patients in Clinical Practice

Thoughtful questions in the history as new pedagogy for teaching patient centred care: A pilot study in an Australian Rural Clinical School (RCS).

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