Teaching medical interviewing. A basic course on interviewing and the physician-patient relationship

Importance of communication in medical practice and medical education: An emphasis on empathy and attitudes and their possible influences

BACKGROUND

Healthcare professionals need to be prepared to promote healthy lifestyles and care for patients. By focusing on what students should be able to perform one day as clinicians, we can bridge the gap between mere theoretical knowledge and its practical application. Gender aspects in clinical medicine also have to be considered when speaking of personalized medicine and learning curricula.

AIM

To determine sets of intellectual, personal, social, and emotional abilities that comprise core qualifications in medicine for performing well in anamnesis-taking, in order to identify training needs.

METHODS

An analysis of training clinicians’ conceptions with respect to optimal medical history taking was performed. The chosen study design also aimed to assess gender effects. Structured interviews with supervising clinicians were carried out in a descriptive study at the Medical University of Vienna. Results were analyzed by conducting a qualitative computer-assisted content analysis of the interviews. Inductive category formation was applied. The main questions posed to the supervisors dealt with (1) Observed competencies of students in medical history taking; and (2) The supervisor’s own conceptions of "ideal medical history taking".

RESULTS

A total of 33 training clinicians (n = 33), engaged in supervising medical students according to the MedUni Vienna’s curriculum standards, agreed to be enrolled in the study and met inclusion criteria. The qualitative content analysis revealed the following themes relevant to taking an anamnesis: (1) Knowledge; (2) Soft skills (relationship-building abilities, trust, and attitude); (3) Methodical skills (structuring, precision, and completeness of information gathering); and (4) Environmental/contextual factors (language barrier, time pressure, interruptions). Overall, health care professionals consider empathy and attitude as critical features concerning the quality of medical history taking. When looking at physicians’ theoretical conceptions, more general practitioners and psychiatrists mentioned attitude and empathy in the context of "ideal medical history taking", with a higher percentage of females. With respect to observations of students’ history taking, a positive impact from attitude and empathy was mainly described by male health care professionals, whereas no predominance of specialty was found. Representatives of general medicine and internal medicine, when observing medical students, more often emphasized a negative impact on history taking when students lacked attitude or showed non-empathetic behavior; no gender-specific difference was detected for this finding.

CONCLUSION

The analysis reveals that for clinicians engaged in medical student education, only a combination of skills, including adequate knowledge and methodical implementations, is supposed to guarantee acceptable performance. This study’s findings support the importance of concepts like relationship building, attitude, and empathy. However, there may be contextual factors in play as well, and transference of theoretical concepts into the clinical setting might prove challenging.

Interventions for improving medical students' interpersonal communication in medical consultations

BACKGROUND

Communication is a common element in all medical consultations, affecting a range of outcomes for doctors and patients. The increasing demand for medical students to be trained to communicate effectively has seen the emergence of interpersonal communication skills as core graduate competencies in medical training around the world. Medical schools have adopted a range of approaches to develop and evaluate these competencies.

OBJECTIVES

To assess the effects of interventions for medical students that aim to improve interpersonal communication in medical consultations.

SEARCH METHODS

We searched five electronic databases: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, PsycINFO, and ERIC (Educational Resource Information Centre) in September 2020, with no language, date, or publication status restrictions. We also screened reference lists of relevant articles and contacted authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster-RCTs (C-RCTs), and non-randomised controlled trials (quasi-RCTs) evaluating the effectiveness of interventions delivered to students in undergraduate or graduate-entry medical programmes. We included studies of interventions aiming to improve medical students' interpersonal communication during medical consultations. Included interventions targeted communication skills associated with empathy, relationship building, gathering information, and explanation and planning, as well as specific communication tasks such as listening, appropriate structure, and question style.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed all search results, extracted data, assessed the risk of bias of included studies, and rated the quality of evidence using GRADE.

MAIN RESULTS

We found 91 publications relating to 76 separate studies (involving 10,124 students): 55 RCTs, 9 quasi-RCTs, 7 C-RCTs, and 5 quasi-C-RCTs. We performed meta-analysis according to comparison and outcome. Among both effectiveness and comparative effectiveness analyses, we separated outcomes reporting on overall communication skills, empathy, rapport or relationship building, patient perceptions/satisfaction, information gathering, and explanation and planning. Overall communication skills and empathy were further divided as examiner- or simulated patient-assessed. The overall quality of evidence ranged from moderate to very low, and there was high, unexplained heterogeneity. Overall, interventions had positive effects on most outcomes, but generally small effect sizes and evidence quality limit the conclusions that can be drawn. Communication skills interventions in comparison to usual curricula or control may improve both overall communication skills (standardised mean difference (SMD) 0.92, 95% confidence interval (CI) 0.53 to 1.31; 18 studies, 1356 participants; I² = 90%; low-quality evidence) and empathy (SMD 0.64, 95% CI 0.23 to 1.05; 6 studies, 831 participants; I² = 86%; low-quality evidence) when assessed by experts, but not by simulated patients. Students' skills in information gathering probably also improve with educational intervention (SMD 1.07, 95% CI 0.61 to 1.54; 5 studies, 405 participants; I² = 78%; moderate-quality evidence), but there may be little to no effect on students' rapport (SMD 0.18, 95% CI -0.15 to 0.51; 9 studies, 834 participants; I² = 81%; low-quality evidence), and effects on information giving skills are uncertain (very low-quality evidence). We are uncertain whether experiential interventions improve overall communication skills in comparison to didactic approaches (SMD 0.08, 95% CI -0.02 to 0.19; 4 studies, 1578 participants; I² = 4%; very low-quality evidence). Electronic learning approaches may have little to no effect on students' empathy scores (SMD -0.13, 95% CI -0.68 to 0.43; 3 studies, 421 participants; I² = 82%; low-quality evidence) or on rapport (SMD 0.02, 95% CI -0.33 to 0.38; 3 studies, 176 participants; I² = 19%; moderate-quality evidence) compared to face-to-face approaches. There may be small negative effects of electronic interventions on information giving skills (low-quality evidence), and effects on information gathering skills are uncertain (very low-quality evidence).  Personalised/specific feedback probably improves overall communication skills to a small degree in comparison to generic or no feedback (SMD 0.58, 95% CI 0.29 to 0.87; 6 studies, 502 participants; I² = 56%; moderate-quality evidence). There may be small positive effects of personalised feedback on empathy and information gathering skills (low quality), but effects on rapport are uncertain (very low quality), and we found no evidence on information giving skills. We are uncertain whether role-play with simulated patients outperforms peer role-play in improving students' overall communication skills (SMD 0.17, 95% CI -0.33 to 0.67; 4 studies, 637 participants; I² = 87%; very low-quality evidence). There may be little to no difference between effects of simulated patient and peer role-play on students' empathy (low-quality evidence) with no evidence on other outcomes for this comparison. Descriptive syntheses of results that could not be included in meta-analyses across outcomes and comparisons were mixed, as were effects of different interventions and comparisons on specific communication skills assessed by the included trials. Quality of evidence was downgraded due to methodological limitations across several risk of bias domains, high unexplained heterogeneity, and imprecision of results. In general, results remain consistent in sensitivity analysis based on risk of bias and adjustment for clustering. No adverse effects were reported.  AUTHORS' CONCLUSIONS: This review represents a substantial body of evidence from which to draw, but further research is needed to strengthen the quality of the evidence base, to consider the long-term effects of interventions on students' behaviour as they progress through training and into practice, and to assess effects of interventions on patient outcomes. Efforts to standardise assessment and evaluation of interpersonal skills will strengthen future research efforts.

Self-awareness rehabilitation after Traumatic Brain Injury: A pilot study to compare two group therapies

BACKGROUND AND PURPOSE

Deficits of self-awareness (SA) are very common after severe acquired brain injury (sABI), especially in traumatic brain injury (TBI), playing an important role in the efficacy of the rehabilitation process. This pilot study provides information regarding two structured group therapies for disorders of SA.

METHODS

Nine patients with severe TBI were consecutively recruited and randomly assigned to one SA group therapy programme, according either to the model proposed by Ben-Yishay & Lakin (1989) (B&L Group), or by Sohlberg & Mateer (1989) (S&M Group). Neuropsychological tests and self-awareness questionnaires were administered before and after a 10 weeks group therapy.

RESULTS

Results showed that both SA and neuropsychological functioning significantly improved in both groups.

CONCLUSION

It is important to investigate and treat self-awareness, also to improve the outcome of neuropsychological disorders. The two group therapies proposed seem to be specific for impulsivity and emotional dyscontrol and for cognitive disorders.

Progress in teaching physician-patient communication in medical school; personal observations and experience of a medical educator

In spite of the enormous progress of Western medicine during the past century there has not be a concomitant rise in the public's satisfaction with the medical profession. Much of the discontent relates to problems in physician-patient communication. The multiple advantages of good communication have been clearly demonstrated by numerous careful studies. While the past few decades have witnessed much more attention given to teaching communication skills in medical schools, there are a number of factors that create new problems in physician-patient communication and counteract the positive teaching efforts. The "hidden curriculum", the increased emphasis on technology, the greater time pressures, and the introduction of the computer in the interface between physician and patient present new challenges for the teaching of physician-patient communication.

A model of professional development for practicing genetic counselors: adaptation of communication skills training in oncology

Ongoing professional development for practicing genetic counselors is critical in maintaining best practice. Communication skills training (CST) workshops for doctors in oncology, utilizing trained actors in role plays, have been implemented for many years to improve patient-centred communication. This model was adapted to provide professional development in counseling skills for practicing genetic counselors, already highly trained in counseling skills. Detailed evidence based scenarios were developed. Evaluation of participants' experience and perceived outcomes on practice included surveys immediately post workshops (2002, 2004, 2005, 2008 (×2); n = 88/97), 2-5 years later (2007; n = 21/38) and a focus group (2007; n = 7). All rated workshops as effective training. Aspects highly valued included facilitator feedback, actors rather than role-playing with peers and being able to stop and try doing things differently. Perceived outcomes included the opportunity to reflect on practice; bring focus to communication; motivation and confidence. The high level of satisfaction is a strong endorsement for ongoing communication skills training in this format as part of professional development.

Provider and patient intervention to improve weight loss: a pilot study in a public hospital clinic

OBJECTIVE

To assess the efficacy of a literacy-appropriate weight loss intervention targeting providers and patients in improving physicians' weight loss counseling and patients' self-reported beliefs, and self-efficacy.

METHODS

The study took place in a public hospital nephrology clinic. The intervention included two physician workshops and a small group patient education. Physician-patient communication was observed and coded. Structured interviews assessed patient recall of weight loss recommendations, weight-related beliefs, and self-efficacy.

RESULTS

64 patient visits were observed before and after the intervention. 75% of patients were African American, 96% lacked private insurance, 71% had low literacy skills; mean body mass index (BMI) of 35 kg/m(2). Physician counseling improved significantly post-intervention, particularly in assessing, supporting and advising patients about weight loss and exercise. Patients reported increases in recall of weight loss recommendations and were more likely to report greater confidence about losing weight (52% vs. 70%, p<0.01).

CONCLUSIONS

This pilot study offers promising directions to address provider and patient barriers to weight loss education and counseling in a public hospital.

PRACTICE IMPLICATIONS

Hospital-based weight loss interventions need to target both physicians and patients.

Development and implementation of communication skills in dentistry: an example from South Africa

Dental students should realise early in their careers -- in dental school -- the importance of developing and mastering sound communication skills with patients. As a result, the aim of this study was to develop and implement a course in communication skills for third year dental students. The methodology employed in the study comprised the following three phases: Phase I: identification of specific outcomes essential for the dentist to be competitive in the emerging South African dental environment. Phase II: development of an outcome-based course according to the South African Qualifications Authority format (Purpose, Embedded knowledge, Assessment criteria). Phase III: implementation of the course. Implementation of the course involved a pre- and post-training cycle. The subjects were 67 third year dental students. The following instruments were employed: a study guide; a case study; an assessment rubric; two questionnaires, namely "Patient's" feedback and "Dentist's" feedback; a standardised patient. The results were as follows: the class as a whole scored significantly higher during training cycle 2 compared with training cycle 1 (P < 0.0001). The important roles of trust, empathy and active listening in establishing a meaningful relationship with a patient, which was conveyed by means of the course, were emphasised by the majority of students.

Four physician communication styles in routine Japanese outpatient medical encounters

BACKGROUND

Few studies have explored how physicians approach medical encounters in Japan.

OBJECTIVE

This study examined how Japanese physicians conduct routine medical encounters in the context of outpatient care to patients with nonmalignant disorders.

DESIGN

Qualitative study using semi-structured interviews and direct observation.

SETTING

The outpatient department of a general hospital located in an urban area of Japan.

PARTICIPANTS

Physicians and nurses providing care and patients receiving care for nonmalignant disorders.

RESULTS

A 2-dimensional model was developed, with patient communication (how physician interacted with patients) along 1 axis, and nurse communication (how physicians collaborated with nursing staff) along the other axis. Four physician communication styles (individually adaptive, individually defined, collaboratively adaptive, and collaboratively defined) were identified as typical ways in which the Japanese physicians in the sample interacted with patients and nurses during routine medical encounters.

CONCLUSIONS

Results suggest the need for a multiprovider-patient model of medical communication among physician, nurse, and patient. Further research is needed to establish the applicability of this model to the communication styles of physicians in other countries.

The effectiveness of a first-year clinical preceptorship on the data collection and communication skills of second-year medical students

BACKGROUND

Evidence suggests that effective physician communication strongly correlates with patient satisfaction and treatment outcome. Unfortunately, teaching these skills has been challenging because of 2 major barriers: (a) medical students are often too preoccupied with the technical and scientific aspects of their curriculum, and (b) it is difficult to expand curricular time.

DESCRIPTION

To overcome these barriers, an educational intervention that has not required additional classroom time was implemented. This first-year preceptorship focused on improving data gathering and interpersonal/communication skills.

EVALUATION

Analysis of the data for the 2 test groups revealed that interpersonal and communication skills were modestly higher in the preceptorship group. There was no significant difference in data collection in each of the two groups.

CONCLUSIONS

Combining formal communication skills instruction with an early clinical experience may prove to be the most effective approach to improving interpersonal, communication, and data gathering skills.

Teaching medical students the important connection between communication and clinical reasoning

BACKGROUND

Medical students are rarely taught how to integrate communication and clinical reasoning. Not understanding the relation between these skills may lead students to undervalue the connection between psychosocial and biomedical aspects of patient care.

OBJECTIVE

To improve medical students' communication and clinical reasoning and their appreciation of how these skills interrelate in medical practice.

DESIGN

In 2003, we conducted a randomized trial of a curricular intervention at Johns Hopkins University School of Medicine. In a 6-week course, participants learned communication and clinical reasoning skills in an integrative fashion using small group exercises with role-play, reflection and feedback through a structured iterative reflective process.

PARTICIPANTS

Second-year medical students.

MEASUREMENTS

All students interviewed standardized patients who evaluated their communication skills in establishing rapport, data gathering and patient education/counseling on a 5-point scale (1=poor; 5=excellent). We assessed clinical reasoning through the number of correct problems listed and differential diagnoses generated and the Diagnostic Thinking Inventory. Students rated the importance of learning these skills in an integrated fashion.

RESULTS

Standardized patients rated curricular students more favorably in establishing rapport (4.1 vs 3.9; P=.05). Curricular participants listed more psychosocial history items on their problem lists (65% of curricular students listing > or =1 item vs 44% of controls; P=.008). Groups did not differ significantly in other communication or clinical reasoning measures. Ninety-five percent of participants rated the integration of these skills as important.

CONCLUSIONS

Intervention students performed better in certain communication and clinical reasoning skills. These students recognized the importance of biomedical and psychosocial issues in patient care. Educators may wish to teach the integration of these skills early in medical training.

Establishing the computer-patient working alliance in automated health behavior change interventions

Current user interfaces for automated patient and consumer health care systems can be improved by leveraging the results of several decades of research into effective patient-provider communication skills. A research project is presented in which several such "relational" skills - including empathy, social dialogue, nonverbal immediacy behaviors, and other behaviors to build and maintain good working relationships over multiple interactions - are explicitly designed into a computer interface within the context of a longitudinal health behavior change intervention for physical activity adoption. Results of a comparison among 33 subjects interacting near-daily with the relational system and 27 interacting near-daily with an identical system with the relational behaviors ablated, each for 30 days indicate, that the use of relational behaviors by the system significantly increases working alliance and desire to continue working with the system. Comparison of the above groups to another group of 31 subjects interacting with a control system near-daily for 30 days also indicated a significant increase in proactive viewing of health information.

Early practical experience and the social responsiveness of clinical education: systematic review

OBJECTIVES

To find how early experience in clinical and community settings ("early experience") affects medical education, and identify strengths and limitations of the available evidence.

DESIGN

A systematic review rating, by consensus, the strength and importance of outcomes reported in the decade 1992-2001.

DATA SOURCES

Bibliographical databases and journals were searched for publications on the topic, reviewed under the auspices of the recently formed Best Evidence Medical Education (BEME) collaboration.

SELECTION OF STUDIES

All empirical studies (verifiable, observational data) were included, whatever their design, method, or language of publication.

RESULTS

Early experience was most commonly provided in community settings, aiming to recruit primary care practitioners for underserved populations. It increased the popularity of primary care residencies, albeit among self selected students. It fostered self awareness and empathic attitudes towards ill people, boosted students' confidence, motivated them, gave them satisfaction, and helped them develop a professional identity. By helping develop interpersonal skills, it made entering clerkships a less stressful experience. Early experience helped students learn about professional roles and responsibilities, healthcare systems, and health needs of a population. It made biomedical, behavioural, and social sciences more relevant and easier to learn. It motivated and rewarded teachers and patients and enriched curriculums. In some countries, junior students provided preventive health care directly to underserved populations.

CONCLUSION

Early experience helps medical students learn, helps them develop appropriate attitudes towards their studies and future practice, and orientates medical curriculums towards society's needs. Experimental evidence of its benefit is unlikely to be forthcoming and yet more medical schools are likely to provide it. Effort could usefully be concentrated on evaluating the methods and outcomes of early experience provided within non-experimental research designs, and using that evaluation to improve the quality of curriculums.

Medical errors: overcoming the challenges

The issue of medical errors has received substantial attention in recent years. The Institute of Medicine (IOM) report released in 1999 has several implications for health care systems in all disciplines of medicine. Notwithstanding the plethora of available information on the subject, little, by way of substantive action, is done toward medical error reduction. A principal reason for this may be the stigma associated with medical errors. An educational program with a practical, informed, and longitudinal approach offers realistic solutions toward this end. Effective reporting systems need to be developed as a medium of learning from the errors and modifying behaviors appropriately. The presence of a strong leadership supported by organizational commitment is essential in driving these changes. A national, provincial or territorial quality care council dedicated solely for the purpose of enhancing patient safety and medical error reduction may be formed to oversee these efforts. The bioethical and emotional components associated with medical errors also deserve attention and focus.

Assessing competence in communication and interpersonal skills: the Kalamazoo II report

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician-patient communication as determined by the participants in the "Kalamazoo II" conference held in April 2002. Communication and interpersonal skills form an integrated competence with two distinct parts. Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship. This report reviews three methods for assessment of communication and interpersonal skills: (1) checklists of observed behaviors during interactions with real or simulated patients; (2) surveys of patients' experience in clinical interactions; and (3) examinations using oral, essay, or multiple-choice response questions. These methods are incorporated into educational programs to assess learning needs, create learning opportunities, or guide feedback for learning. The same assessment tools, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, become a summative evaluation. The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic. Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physician's competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.

Empathic communication and gender in the physician-patient encounter

Although empathy in the physician-patient relationship is often advocated, a theoretically based and empirically derived measure of a physician's empathic communication to a patient has been missing. This paper describes the development and initial validation of such a measure, the Empathic Communication Coding System (ECCS), which includes a method for identifying patient-created empathic opportunities. To determine the extent to which empathic communication varies with physician and patient gender, we used the ECCS to code 100 videotaped office visits between patients and general internists. While male and female patients created a comparable number of empathic opportunities, those created by females tended to exhibit more emotional intensity than those created by males. However, female patients were no more likely than male patients to name an emotion in their empathic opportunities. Physician communication behavior was consistent with the literature on gender differences: female physicians tended to communicate higher degrees of empathy in response to the empathic opportunities created by patients. The ECCS appears to be a viable and sensitive tool for better understanding empathy in medical encounters, and for detecting modest gender differences in patients' creation of empathic opportunities and in physicians' empathic communication.

An assessment of residents' abilities to detect and manage domestic violence

Despite increased awareness of domestic violence (DV), little is known about residents' preparedness to diagnose and respond appropriately to abuse victims. We designed a pilot study to examine this. Seventy-one internal medicine residents participated in a 10-station standardized patient-based Clinical Skills Assessment. Forty (56%) were male and 31 (44%) were female; 46 (65%) were PGY I; 63 (89%) were trained internationally. One station presented a woman with headaches, whose underlying issue was DV. Forty (56%) residents correctly diagnosed DV. Thirty referred the patient for DV counseling. Eighteen addressed immediate safety concerns, and 23 asked about child abuse. Forty-eight (68%) made 1 or more incorrect recommendations. Thirty-six (51%) ordered unnecessary tests. Residents who did not diagnose DV spent nearly twice as much per patient on work-up (mean, $942.00), compared to those who diagnosed DV (mean, $421.00). Use of certain interviewing skills appeared to promote elicitation of DV. Assessment-driven educational interventions could help trainees improve their recognition of DV and make appropriate and cost-effective management choices.

Becoming a doctor: fostering humane caregivers through creative writing

We qualitatively examined themes covered in a creative writing elective designed to enhance pre-clinical medical students' writing, observation, and reflection skills relative to experiences in their medical education. Qualitative analysis of writings' themes was carried out via iterative consensus building process and validated through member checks and literature review. Fourteen students completed the elective, seven for each year it was given. Students submitted 86 written pieces. Qualitative analysis demonstrated the presence of nine themes: students' role confusion, developing a professional identity, medicine as a calling, physician privilege and power, humanizing the teacher, the limits of medicine, death and dying, anticipating future challenges, and identification with the patient. Students evaluated this creative writing course favorably, indicating value in writing and reflection. Themes covered are of concern to second-year medical students as well as other trainees and practicing physicians. Writing may aid in the professional development of physicians.

The SEGUE Framework for teaching and assessing communication skills

This article examines uses and characteristics of the SEGUE Framework, a research-based checklist of medical communication tasks. A recent survey of US and Canadian medical schools indicates that the SEGUE Framework is the most widely used structure for communication skills teaching and assessment in North America. Student and faculty response to the SEGUE Framework as a teaching tool has been positive. Data drawn from clinical skills assessments with standardized patients provide evidence of concurrent and construct validity. Analysis of visits between general internists and their patients reinforces validity of the SEGUE Framework in an actual practice setting. Interrater reliability is high when standardized patients are recording student performance immediately after a live encounter, and when coders are evaluating videotaped or audiotaped encounters; intrarater reliability is strong as well. The SEGUE Framework has a high degree of acceptability, can be used reliably, has evidence of validity, and is applicable to a variety of contexts. Studies of predictive validity are needed.

Reinforcement of occupational history taking: a success story

BACKGROUND

This article describes the results of a retrospective study of 3 classes of medical students who participated in a targeted occupational and environmental health curriculum at the University of Connecticut School of Medicine.

PURPOSE

We wanted to determine if targeted focused curricular interventions which integrated occupational and environmental health principles into routine history taking would result in increased scores on the number of questions posed during the Clinical Skills Assessment Program in the 4th year.

METHODS

We analyzed Clinical Skills Assessment Program questions for 3 graduating medical school classes from 1997 to 1999.

RESULTS

It appears that intense, focused training may increase the occupational and environmental questions which students ask. By revisiting the components of the history during the 3rd year, the final assessment of 4th-year students substantially and significantly increased.

CONCLUSIONS

Those who wish to stem the decline in history-taking skills as students enter their clinical years should consider reinforcing these skills using structured programs and practice in areas of the history that are traditionally neglected but recognized as essential in gathering comprehensive data on patients.