1. 1 Participants and grouping
The participants in this study were recruited from five classes of the 2019 batch of junior undergraduate students majoring in clinical medicine who participated in the May–June 2023 history-taking diagnostic laboratory course at Guizhou Medical University, with the number of students in each class ranging from 125– 130, for a total of 633 students. Students in each class were divided into 24 groups by the random number table method, and each group numbered from 1–24 had 5–6 students. The groups numbered 1 + 3n (n ≥ 0) were the TSP groups, which could obtain the chief complaint of the interrogation case but did not inform the disease diagnosis; the groups numbered 2 + 3n (n ≥ 0) were the
spRP groups, which could obtain the script of the interrogation case but did not inform the disease diagnosis; the groups numbered 3 + 3n (n ≥ 0) were the non-spRP groups, which were required to write the corresponding case scripts based on the chief complaints and disease diagnoses of the cases to be interrogated. Each group contained eight teams with 5–6 students each. The students playing the patients in spRP and non-spRP groups were selected by lottery. All students provided informed consent before participating in the study.
1.2 Teaching arrangement
All students had completed theoretical lectures on diagnostic symptomatology and history taking before undergoing the diagnostic laboratory course on history taking. Students in each class had two sessions of four hours each distributed over two weeks and for the same chapter, all of the students were taught by the same teacher. The specific teaching schedule is as follows.
1.2. 1 pre-coursepre-course preparation stage
1) Preparation of the consultation case: The lecturers carefully prepared the consultation case through discussions and determined the final version.
2) SP training: The students in the TSP group were clinical professionals currently engaging in full-time teaching. All of them had experience acting as SPs and conducting clinical skill assessments; therefore, they only underwent SP training in this study without SP assessment. The lecturers conducted SP training for the selected SSPs the day before the course and instructed and assessed all SSPs on the spot, and all of them passed the assessment.
3) Prepost-course self-assessment evaluation form was sent before the course and each student was asked to fill out the formpre-course.
1.2.2 Implementation phase
1) The first session (four class hours): First, a lecture on consultation skills and assessment criteria
was delivered (0.5 hours); after that, each group was trained to conduct consultations ( 1.5 hours). The interrogation targets of the TSP groups were the teachers and that of the RP groups were SSPs selected in advance. After the training, each group was required to conduct a consultation exercise (2 hours), and the students were free to decide on the interrogating doctors (2 people) and commentators (2–4 people). The consultation time of each group was limited to 10 minutes, and the commentators were given five minutes to review the consultation, followed by 5-minute feedback from the TSP/SSP. There were six teachers to supervise the courses and answer questions.
2) The second session (four class hours): This was conducted in the form of lectures, with the main goal of developing students' clinical thinking skills. Based on the consultation cases in the first session, discussions were held on the diagnosis process, such as how to obtain information related to the diagnosis from the consultation, how to conduct the consultation focusing on the main symptoms and disease characteristics, how to give a diagnosis based on the content of the consultation, what is the basis of the diagnosis, and what are the targeted treatment measures. At the end of the course, students filled out the post-course self-assessment form on interviewing skills and answered a questionnaire.
3) Assessment: One week after the course, an examination was conducted in groups with real patients as the object of consultation, who had a stable state of illness and were willing to cooperate in clinical assessment. Each class selected 12 patients and communicated with them in advance, with each patient consulted by two students. The objects of the consultation were chosen by random draw, and two students
from each group were selected by lottery to play the role of doctors for the consultation ( 10 minutes), and the rest of the students acted as reviewers (5 minutes). After the consultation, the groups were asked questions related to clinical thinking ability and each student was required to submit a complete medical record after one day.
Six teachers were divided into groups of two to assess eight groups of students. To limit the influence of subjective factors of teachers, each group of assessment teachers took turns to assess different subgroups of each class.
1.3 Teaching effect evaluation
1.3. 1 Teaching effect assessment included group as well as individual assessment.
The group-based assessment included consultation assessment (accounting for 80%) and process assessment (accounting for 20%), with a total score of 100 points. The individual assessment comprised an assessment of medical record writing, totaling 100 points.
1) Consultation assessment is divided into two parts: completeness of history taking and doctor-patient communication skills assessmen:
① Completeness of history taking (83 points, accounting for 60%): general items (5 points), chief complaint ( 10 points), present medical history (45 points), medical history (8 points), personal history (6 points), marital history (4 points), and family history (5 points). The present medical history includes onset (3 points), causes or triggers (4 points), characteristics of the main symptoms (8 points), development and evolution of the condition (5 points), concomitant symptoms ( 11 points), diagnosis and treatment process (7 points), and general conditions during the course of the disease (7 points).
② Doctor-patient communication skills assessment (75 points, accounting for 20%): Based on the Arizona Clinical Interview Rating (ACIR) Scale, interrogation skills include completeness of interrogation, organization, transitional language, continuity, avoiding induced questions, avoiding repetitive questions, summarizing, avoiding medical jargon in questions and citation verification; the humanistic care aspects include eye contact, avoiding inappropriate interruptions to patients, deep dialogue to alleviate patient's concerns, supporting and praising the patient, encouraging the patient to ask questions, and introducing oneself to the patient and explaining the purpose; the last item is a new addition. There are a total of 15 items, including 9 items for interrogation skills (a total of 45 points) and 6 items for humanistic care (a total of 30 points)16.
2) Process assessment contains the following three parts, with a total of 60 points:
① Reviewers: Whether the review is reasonable and comprehensive, and whether all reviewers are active speakers, each accounting for 5 points, for a total of 15 points.
② Clinical thinking assessment: a) whether the information obtained through interrogation can lead to a clear diagnosis; b) whether the disease diagnosis is correct; c) Whether their inference about the further inspection the patients need and their possible positive signs is correct; d) correctness of their deduction about the patients’ possible positive physical signs; e) correctness of their deduction about the ancillary tests the patient needs and possible abnormalities; f) whether the diagnostic basis is adequate; whether the treatment measures are targeted (5 points for each, 30 points in total).
③ Teamwork: a) high participation of team members in class; everyone actively participated in the
discussion of medical records; b) completion of pre-course preparation and post-simulation assignments by team members; c) no truancy, tardiness, or early departure by team members (5 points for each, 15 points in total).
3) Medical record writing: assessed on an individual basis with a total score of 100 points.
1.3.2 Students’ degree of satisfaction with the course
Satisfaction with the course was evaluated on a 5-point Likert scale, ranging from 1 (strongly dissatisfied/disapproved) to 5 (strongly satisfied/strongly approved), based on the following three dimensions: ① evaluation of the overall attitude toward the course (6 items); ② evaluation of attitude toward clinical skills development (3 items); ③ evaluation of attitude toward teamwork (4 items). All are described by mean scores, with 3.5 or more indicating positive attitudes.
1.3.3 Self-assessment of history-taking skills
Self-assessment of history-taking skills includes the comparison of pre-course and post-simulation evaluations based on 12 items, scored from 1 (strongly disagree) to 6 (strongly agree), with the total score ranging from 12–72 points, as detailed in Table 1.
Table 1
Self-assessment of history-taking skills
Item
|
Content
|
1. Your class
|
fill in the blanks
|
2. Which teaching method are you practicing
|
options: SP;spRP༛non-spRP
|
Content of self-assessment
|
Score 1–6: Strongly disapprove – strongly approve
|
1. I was able to get the patient's history in an organized way
|
Pre-course score:
|
Post-course score:
|
2. I can get complete information on the main symptoms
|
Pre-course score:
|
Post-course score:
|
3. I have access to the patient's complete history of present disease
|
Pre-course score:
|
Post-course score:
|
4. I can obtain complete and meaningful information about
the patient’s past medical history
|
Pre-course score:
|
Post-course score:
|
5. I have access to complete personal history information
|
Pre-course score:
|
Post-course score:
|
6. I have access to complete family history information
|
Pre-course score:
|
Post-course score:
|
7. At the end of each project, I can use transition language
to naturally transit to the next project
|
Pre-course score:
|
Post-course score:
|
8. At the end of each interrogation, I can summarize the findings
|
Pre-course score:
|
Post-course score:
|
9. I can perform case analysis and summarize the results of the interrogation
|
Pre-course score:
|
Post-course score:
|
10. I can give appropriate feedback on the patient's status
|
Pre-course score:
|
Post-course score:
|
11. I can listen patiently to the patients and do not interrupt them easily
|
Pre-course score:
|
Post-course score:
|
12. I am confident in building a good and trusting doctor-patient relationship
|
Pre-course score:
|
Post-course score:
|
Note: TSP=teacher standardized patient, spRP=scripted role play, non-spRP=non-scripted role play
1.4 Statistical methods
1) All results were analyzed using SPSS 23.0 statistical software.
2) All assessment scores were described by rate (%), and the measurement data were described by (± s). The differences between groups were analyzed by one-way ANOVA with post hoc comparisons corrected by the least significant difference (LSD) test; the count data were described by composition ratio (%) and post hoc comparisons were corrected by the Bonferroni method.
3) Analysis of self-assessment scores: One-way ANOVA was used to analyze the differences between the groups' scores before and after the course, and the paired-sample t-test was used for analyzing the differences within the groups.
4) Questionnaire reliability test: Before administering the questionnaire, the director of the internal medicine faculty and the group leader of diagnostics were invited to participate in the overall evaluation and screening of the conceptual dimensions, overall structure, question design, and option arrangement of the questionnaire. The questions were assessed for reliability using Cronbach 's α (coefficient > 0.6 was considered acceptable) and validated using exploratory analysis (Kaiser-Meyer-Olkin, KMO) and Bartlett s’ sphericity test.