Personal view or opinion piece
Open Access

Don’t sleep on history-taking: reflections from student and teacher in the telehealth era

Mark Brahier[1], Nancy Barr[2]

Institution: 1. Georgetown University Medical Center, 2. MedStar Franklin Square Medical Center
Corresponding Author: Mr. Mark Brahier ([email protected])
Categories: Curriculum Planning, Students/Trainees, Teaching and Learning, Technology, Clinical Skills
Published Date: 12/01/2021

Abstract

The COVID-19 pandemic has prompted a new sense of urgency within medical education to adapt to the telehealth era. In this opinion piece, we call for a recommitment to the core tenants of clinical education, namely history-taking skills, that will remain foundational in the telehealth era.  We challenge students to seek opporturtunities to develop these skills in the in-person setting so that they might better translate to telehealth in the future.

Keywords: undergraduate medical education; telehealth; COVID-19 curriculum; history-taking

Introduction

“New admission for you,” my senior resident said.  “Why don’t you plan to present the full history and physical?”  Little did I know this would be my final in-person patient interaction before clinical education halted, ironically due to a novel infectious disease that the entire medical community needed to learn. As I approached the patient’s room, a young attending grabbed my arm. “Chief complaint bloody stool, recent history of colonic mass,” he told me and winked. I smiled and nodded but wasn’t sure whether I should thank him for “gifting” me a preliminary diagnosis or ask for the next patient so I could start from scratch.

Clinical Medical Education: Past, Present, and Future

There has always been value to the unknown in clinical medical education. Greek texts dating to the fifth century B.C. point to a system of apprenticeship in medical education in which students would first observe a master at work and then perform all steps of healing beginning from the unknown (Fulton, 1953). This metaphorical blank slate paired with relative abundance of time encourages the twenty-first century learner to organize a thorough history, perform relevant physical exam maneuvers, and formulate a differential diagnosis. Upon leaving the hospital that day, I, like many other students across the world, wondered what the future of medical education would be both in the short and long term.

 

Even prior to the recent pandemic, the emerging telehealth era had challenged traditional medical school curricula in the realm of clinical education (Waseh and Dicker, 2019). Educational institutions sought to utilize virtual platforms and technologies to prepare their students for an uncertain future. Since COVID-19, medical schools have hastened efforts to integrate telehealth into undergraduate education in ways that could change pedagogy forever (Buckley, 2020).

Telehealth Curriculum

My medical school was among those at the forefront of change, rapidly implementing COVID-19 and telehealth curricula in an effort to adjust to the changing demands of the medical profession. Our professor started the telehealth course with a counterintuitive claim: “Telehealth is the new house call.” It is the means by which we, as providers, enter the homes and environments of our patients.

 

In speaking to providers across many specialties over the course of two weeks, we quickly learned that tele-appointments fit medicine’s mantra of “see one, do one, teach one.” Numerous guest lecturers introduced themselves in the same way: as a physician who is learning this technology alongside us. Few had received formal training in telemedicine. Fewer claimed to be experts. Most specialties were still learning the basics of telehealth, while others such as the solid organ transplant department were working like a well-oiled machine. Specialties such as electrophysiology had already been familiar with the use of remote monitoring devices.

 

Twice during the course, we had opportunities to practice with virtual standardized patients, who themselves were learning to role-play in this new environment. These virtual standardized patient appointments exposed a learning curve among medical students who had never previously experienced this type of patient interaction. With limited ability to obtain vital signs, perform a physical exam, and conduct point of care testing, we spent a refreshing majority of the visit speaking with the patient. The lesson was simple: we do better for our patients by listening to their stories anyway. The circumstances of telehealth just force the hand.

 

I asked my professor about the experience teaching telehealth for the first time. How do you teach something you just learned and are learning still? Her response: “Teaching something completely new means being completely honest with the learners. I am not the master at work in telehealth; I am the doctor trying to make it work for our patients. The course was designed to give a taste of telehealth to our students so that they would have a familiarity that was not afforded to practicing physicians in 2020. Not only was the content new, the teaching format was new as we were teaching remotely. Didactic styles and curriculum design had to also change on the fly to make the course meaningful, practical, and interesting.”

Conclusion

In a profession marked by change, we must consider the core tenants of medical education that will endure, as well as skills that future medical practice will demand. In a time of uncertainty, of what can we remain certain? Whether in-person or virtual, excellent history-taking skills must remain a cornerstone of clinical medical education. Many educational interventions have proven efficacious in improving history-taking skills (Keifenheim et al., 2015), and trainees will continue to need rigorous in-person training should these skills translate to telehealth. Accordingly, clinical instructors must continue encouraging their students to undergo full repetitions of the history and physical examination. Such practices are of increased importance when shaping future physicians who will rely heavily on a patient’s story during telehealth appointments where reliable, objective data currently lags behind that of an in-person visit. Don’t sleep on history-taking, particularly when it’s all we have.

Take Home Messages

  • The COVID-19 pandemic has brought a new sense of urgency to development of telehealth curricula in undergraduate medical education
  • Many physicians teaching telehealth to trainees are learning the technology for the first time themselves
  • History-taking skills must remain a core tenant of clinical medical education whether applied to an in-person or virtual setting

Notes On Contributors

Mark Brahier, BS is a fourth-year medical student at the Georgetown University School of Medicine and MBA student at the Georgetown McDonough School of Business.

Nancy Barr, MD is The Director of Medical Student Education and Medical Director of the Family Health Center at MedStar Franklin Square Medical Center in Baltimore, Maryland. She designed and taught the Georgetown University School of Medicine’s inaugural telehealth course.

Acknowledgements

None.

Bibliography/References

Buckley, M. R. F. (2020) Harvard Medical School uses telemedicine as a way forward, Harvard Gazette. Harvard Gazette. Available at: https://news.harvard.edu/gazette/story/2020/05/harvard-medical-school-uses-telemedicine-as-a-way-forward  (Accessed: 7 September 2020).

Fulton, J. F. (1953) 'History of Medical Education', BMJ, 2(4834), pp. 457–461. http://doi.org/10.1136/bmj.2.4834.457

Keifenheim, K. E., Teufel, M., Ip, J., Speiser, N., et al. (2015) 'Teaching history taking to medical students: a systematic review,' BMC Medical Education, 15(1). http://doi.org/10.1186/s12909-015-0443-x

Waseh, S. and Dicker, A. P. (2019) 'Telemedicine Training in Undergraduate Medical Education: Mixed-Methods Review', JMIR Medical Education, 5(1). http://doi.org/10.2196/12515

Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

This is an opinion piece and did not require ethics approval.

External Funding

This article has not had any External Funding

Reviews

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Ken Masters - (09/04/2021) Panel Member Icon
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An interesting opinion piece on early impressions of history-taking in telemedicine.

I think the paper offers some nice insight into these early impressions and the importance of history-taking when using telehealth, although the paper does also wander a little, and talks about telehealth education in general.

Given that the authors will now have had more experience with telehealth, it would probably be useful if they could write a more in-depth reflective piece that would give greater guidance to readers regarding specifics, especially new advantages on the topic offered by telehealth and the difficulties encountered, and how they can be managed.



Possible Conflict of Interest:

For transparency, I am an Associate Editor of MedEdPublish.

Annwyne Houldsworth - (27/01/2021)
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Thank you for highlighting this very interesting and current area of innovation for medical education and congratulations in the progress made in this area.
The paper addresses the new era of telehealth, particularly accelerated into use by the COVID 19 pandemic, where the new requirement for virtual platforms and technologies must be integrated into the medical training curriculum, including virtual history taking.
The metaphor from the author about the ‘blank slate’ was an interesting aspect about history taking. History taking without prior information could have some similarities to problem based learning principles, where the practitioner is presented with the unknown condition of a patient and has to decide which information is relevant in order to determine the strategies to follow in order to treat the patient with those facts. The capacity to recognise and retrieve the unknown, while responding to the unpredictability of the situation must be made even less transparent by the physical absence of the patient. Objectivity may be an advantage to diagnosis whereas previous patient doctor relationships may be more subjective. Thus previous information about a patient may be better shared at a later time, if at all.
Also greater degree of observation may be required, without the usual clinical tools available to the practitioners and methods of training in this must be further developed.
May it be required to consider various aspects of training for the patient population as well, with advice about what kind of descriptions and communications that are helpful to the clinician.
The author’s comment on listening skills was interesting and the idea of improving these skills through telehealth training is intriguing. Would face-to-face appointments in the surgery be improved if doctors were also experienced in telehealth history taking, having enhanced their listening skills?
It is very refreshing to hear about the teacher and the learner exploring virtual history taking together. This is an increasingly common experience in today’s education, where ‘technology immigrants’ are teaching ‘technology natives’ with facilitation roles are more important than the didactic presentation of facts. Again, may some of the principles of problem-based learning apply but this situation to both student and lecturer?
Possible Conflict of Interest:

None

BALAJI ARUMUGAM - (19/01/2021) Panel Member Icon
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This is a good personal opinion on the current paradigm shift towards virtual learning platform and the medical teachers struggling to learn the technology and make the content student friendly while delivering the topics. To my experience for the past 6 months in teaching the medical students via virtual platform was a big task as every platforms has its own usage pattern and the students were not at all comfortable in learning because of various factors. Practical / clinical sessions were very tough in organizing and delivering as many students had language issues. Students from various language backgrounds has to talk to patient personally / directly while taking history. Anyway the months passed on and we were able to impart some knowledge on clinical session in stead of nothing.
Possible Conflict of Interest:

NONE

Mary Higgins - (12/01/2021)
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This is not a review but more of a comment - I really liked your opinion piece - and especially the insight of this being the new home visit. We will be citing your opinion piece in our virtual learning on history taking and thank you!