How medical students learn to 'take histories' from patients

Abstract

‘Taking a history’, or talking to a patient to find out their medical problems, is the first clinical skill learned by medical students.  It is of major importance in making diagnoses, is often done badly, and influences the outcome for patients.  However, there is little agreement about what constitutes a ‘good history’.  Students receive conflicting messages about how they should ‘take a history’, are rarely observed doing it and see doctors ‘taking histories’ using a method quite different from conventional teaching.

This study explored medical students’ and teachers’ views on the purposes and rationale for ‘taking a history’, the influences on these and students’ approaches to learning this skill.  A theoretical framework for the learning process was used to develop research questions and to inform the methodology, which comprised individual and group interviews with a sample of third and fifth year medical students and teachers.  These were analysed during a constant comparative method, and this gave rise to an exploratory model for the task of learning to ‘take a history’, which conceptualises three perspectives on ‘history taking’.  The doctor-practitioner perspective sees the student’s role when ‘taking a history’ as acting as a doctor to gather selective information in order to make a diagnosis and plan patient care.  The student-clerk perspective sees the student’s role as a clerk, collecting comprehensive information about a patient for the purpose of reference, and as part of the traditional culture of medical education.  The patient-person perspective sees the student as a person talking with another person (the patient) about their medical problems, engaging with their individual context and concerns.  This three perspective model, through specific to this one skill, is in line with the work of other writers on the overall culture of medical education.

Two key conclusions are reported.  Firstly, the tensions between the perspectives, many of which were never made explicit, tended to encourage students to take a surface approach to learning in the early stages, and to ‘play the game’ in later stages.  Secondly, the perspectives model offers a theoretical framework which could facilitate discussion of the current tensions and inform curriculum development, with the ultimate aim of improving health care of patients.

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