Often our best educational ideas just pop into our head. I was trying to find a way to teach new first year students how to develop their history taking skills. Taking a history is much more than just following a mnemonic with the right information in it. History taking is a nuanced and evolutionary process as people add more and more questions to their history taking repertoire. Ultimately students will be able to take histories more intuitively with less reliance on rigid frameworks, but at this stage we are concentrating on getting them used to the history taking framework and communicating with patients.
At our institution we use the CHAMPSS (Chief complaint, History of chief complaint, Allergies, Medications, Past medical history, Social history, Systems review) approach to history taking. However this activity will work with any history taking system (SAMPLE, etc) and whilst not tested under these conditions, could be used for a longer approach; for example for a medical history in a primary care setting.
Preparing the Activity
To set up this activity, we prepared for the activity by:
- Creating a set of six patient histories. These were a page to a page and half long and written in the CHAMPSS model for the ease of the students playing patients. The length of the histories were designed to reflect a basic low to mid-acuity medical complaint which a paramedic might be called for. It was assumed that all patients were fully conscious and did not have a time-critical condition. An example is shown below.
- Setting up chairs in pairs, organised in a circle (see diagram below). We used between six and eight pairs depending on the group size.
Running the Exercise
Students were briefed on the activity. They had previously had a one hour lecture on taking a patient history and had seen a video demonstration on our e-learning platform.
To run the activity, the students assumed seats on the concentric circles of chairs. Each history taking session was allocated seven minutes of time. Students were briefed that if they finished before the seven minute park, they should discuss the scenario with their partner and seek feedback on their history taking. This allowed them to see what information in the scenario they missed and get feedback on what other questions they could have potentially asked.
After the second and the fourth scenarios, students were given feedback on their progress from the educator who had been running the session. The students were also given additional tips to incorporate in their practice. In this case, after the second scenario students were advised to think about the language they used and how patients from different backgrounds would react or understand their questions. For example, what would a patient do if you simply said “please outline your social history.” After the fourth scenario, students were advised to try repeating the history back to the patient to confirm the accuracy of their history taking and practice summarising for later handovers.
The entire exercise, with briefing time generally took between fifty five minutes and an hour using six scenarios.
We ran the exercise eight times. On each occasion students seemed to engage well, ask insightful questions and steadily improve their history taking skills across the six scenarios.
We plan to use the activity again in a few weeks when we introduce pain assessment. In this case we will likely run five scenarios in an hour with a ten minute time frame to do both CHAMPSS and the SOCRATES pain assessment. This activity could also potentially be used for simple mental health assessments.
The patient is a 27 year old female who has called an ambulance after collapsing at home.
The patient has collapsed after feeling dizzy. This was abnormal for her. She thinks she was unconscious for a short time then woke up.
History of Chief Complaint:
- The patient had been feeling unwell that day. She was off work sick after having flu like symptoms. She feels tired and run down and slightly sick to her stomach. She has not vomited.
- The patient was walking from her bedroom to her kitchen. As she was walking she suddenly felt weak in her legs and dizzy then blacked out.
- The patient thinks she only blacked out for a few seconds
- After she blacked out she managed to get to her sofa then call 000
- The patient has not had this happen before. She is very worried about the episode.
- The patient has not been eating or drinking normally since she has been sick. This has been going on for about 36 hours.
- The patient has not been going to the toilet as often as normal and her urine has been very dark.
- The patient is allergic to penicillin. It gives her a bad rash and makes her sick to her stomach.
- The patient takes iron supplements because she has mild anaemia. She has not been taking her medication since she has been sick.
Past Medical History:
- The patient has a history of iron deficiency and anaemia. This makes her tired and lethargic normally.
- The patient has a history of mild anxiety and sometimes has panic attacks.
- The patient normally eats well but has been staying back late at work a lot and forgetting to eat. She does not exercise much.
- The patient lives alone. Her family lives in another city around 800 km away so she does not see them much.
- The patient has a job as a teller at a bank. She has been under a lot of pressure at work because the bank has been downsizing and is likely to close her branch. She does not get on with her manager so she thinks she will lose her job.
- The patient does not go out much. She has a few friends but mostly stays at home.
The paramedic will go on to check vital signs and then do some tests to check her cardiovascular, respiratory and gastrointestinal system.