Quality Improvement project in surgical education: Focused history-taking communication skills

Dr

Reece Patel

and Dr Khalil Saadeh School Of Clinical Medicine, University of Cambridge

Introduction

There is an abrupt transition from the preclinical to the clinical course at the University of Cambridge. This is similar across many medical curricula in the UK. Thus, students suddenly undertake clinical placements where they are expected to take histories and examine patients with little preparation or formal instruction Most students find this a daunting task.

Incoming clinical students consistently report that they lack confidence in their history-taking ability and feel underprepared for communication skills exams

Aims

Using quality improvement methodology, we aimed to develop a teaching programme that would increase fourth-year medical students’ confidence in clinical history taking and preparation for assessments as measured via a targeted questionnaire over a 6-week clinical rotation.

Methodology

The teaching programme was offered to fourth-year University of Cambridge medical students at Ipswich hospital. Students completed a baseline questionnaire which was used to gauge student preparedness and confidence in history-taking skills.

The programme followed QIP methodology consisting of three Plan-Do-Study-Act (PDSA) cycles:

Comparisons made of student preparedness and confidence against baseline levels allowing identification of which aspects of the teaching programme students found most useful.

A history taking teaching programme was created and offered to medical student’s due to student’s feeling underprepared

Cycle 1 – Peer with supervisor practice

Outcomes were assessed using a post-session questionnaire

Comparisons made of student preparedness and confidence against baseline levels allowing identification of which aspects of the teaching programme students found most useful.

Cycle 2 –

With Peer Practice

Outcomes were assessed using a post-session questionnaire

Identified that students would struggle to know ‘how’ to ask delicate questions. We decided if the student acted as the patient they could discover how they would respond to different questions

Comparisons made of student preparedness and confidence against baseline levels allowing identification of which aspects of the teaching programme students found most useful.

Students identified that they would want to complete the clinical scenario with a relevant examination

Cycle 3 –History and examination practice

a supervisor

Results

Baseline:

• Baseline questionnaires showed students had a low level of confidence in history-taking (Mean=3.1/5) and preparedness for final year exams (Mean=2.4/5). It also showed that 78.6% of students would like more practice in history-taking.

Cycle 1 – Peer with supervisor practice:

• After Cycle 1 both confidence in history-taking (Mean=3.9/5) and preparedness for final year exams (Mean=3.8/5) increased

• 100% students found receiving feedback with a clear mark-scheme useful

Cycle 2 – Peer with peer practice:

• Cycle 2 showed 77.8% found practicing with peers more useful than with a supervisor.

Cycle 3 – History and examination practice:

• Cycle 3 had the highest confidence in history-taking (Mean=4.1/5) and preparedness for final year exams (Mean=4.0/5).

Cycle 2 implemented a focused history-taking session involving peer-topeer history taking practice

Outcomes were assessed using a post-session questionnaire

Key findings

Cycle 3 involved peer-topeer history taking practice followed by an examination of the relevant system.

Combined key findings from all three cycles to be recommended for implementation in future teaching programmes aimed at improving history taking skills are:

• Use of structured mark schemes for feedback

• The opportunity to practise structured viva

• The opportunity to practise history taking and viva under exam timing

• Students acting as the patient for the history taking session

• Combining an examination of the relevant system following history-taking practice