Quality of Medical History Taking and Diagnostic Accuracy

Study Overview
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Brief Summary
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This prospective randomized simulator-based single-blind trial aimed to investigate the effects of initial cues and history taking skills on diagnostic accuracy

Detailed Description
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Diagnostic errors are a relevant health-care problem. As medical history taking is usually the first step in a patient's assessment its quality is most likely a first and important barrier against diagnostic errors. There are, however, only limited data on the association of the quality of medical history taking and diagnostic accuracy.This prospective randomized simulator-based single-blind trial aimed to investigate the effects of initial cues and history taking skills on diagnostic accuracy. 198 medical students (135 females) were given the task to assess a patient presenting with simulated acute pulmonary embolism. Participants were randomized to six versions of the scenario differing only in the initial cues, i.e. in the reply of the patient to the initial question about the reason for his visit. In three of six versions, initial cues were restricted to thoracic symptoms (chest pain, dyspnoea, or combination of both). In the remaining three versions, initial cues consisted of thoracic and extra-thoracic (leg pain, immobilization) symptoms. The primary outcome was diagnostic accuracy. The mannequin was equipped with a speaker in its head that broadcasts the voice of a remote operator (experienced physician) allowing verbal interaction of the participants with the patient. The patient did not speak unless asked and responded to all participants' questions during history taking according to a pre-defined checklist.

Official Title
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Effects of Initial Cues and the Quality of Medical History Taking on Diagnostic Accuracy

Conditions
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Diagnostic Error

Intervention / Treatment
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* Other: Initial cue


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 4th year medical students participating in voluntary simulator-based workshops Exclusion Criteria: decline to give written informed consent

Ages Eligible for Study
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Minimum Age: 20 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Participants were randomized (computer-generated numbers) to six versions of a simulated scenario of pulmonary embolism. The six versions differed only in the initial cues, i.e. in the reply of the patient to the initial question about the reason for his visit.
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Chest pain<br>Patient answers the initial question of history taking on why he had come to the hospital with Chest pain | Other: Initial cue<br>* Symptom volunteered by the patient<br>|
| Experimental: Dyspnoea<br>Patient answers the initial question of history taking on why he had come to the hospital with Dyspnoea | Other: Initial cue<br>* Symptom volunteered by the patient<br>|
| Experimental: Chest pain AND Dyspnoea<br>Patient answers the initial question of history taking on why he had come to the hospital with Chest pain, and Dyspnoea | Other: Initial cue<br>* Symptom volunteered by the patient<br>|
| Experimental: Chest pain AND dyspnoea, AND leg pain<br>Patient answers the initial question of history taking on why he had come to the hospital with Chest pain, and Dyspnoea, and leg pain | Other: Initial cue<br>* Symptom volunteered by the patient<br>|
| Experimental: Chest pain AND dyspnoea, AND immobilization<br>Patient answers the initial question of history taking on why he had come to the hospital with Chest pain, and Dyspnoea, and immobilization | Other: Initial cue<br>* Symptom volunteered by the patient<br>|
| Experimental: Chest pain AND dyspnoea, AND leg pain AND immobilization<br>Patient answers the initial question of history taking on why he had come to the hospital with Chest pain, and Dyspnoea, and leg pain, and immobilization | Other: Initial cue<br>* Symptom volunteered by the patient<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Stating the correct diagnosis | At the end of the study time (5 minutes), a study physician enters the simulator room and asks the participate on his/her presumptive diagnosis. Simualtions are video-taped and the analysis of the outcome is performed by trained observers by video analysis. Stating the correct diagnosis is a binary outcome, rated either as yes (correct presumptive diagnosis of pulmonary embolism is stated) or no (correct presumptive diagnosis of pulmonary embolism is NOT stated). | 5 minutes | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Depth of history taking | Data analysis is performed using video-recordings recorded during scenarios. Trained observers note kind and timing of all questions. Questions were categorized in six pre-defined categories (chest pain, dyspnoea,associated symptoms, risk factors for pulmonary embolism,cardiovascular risk factors, personal history). Depth of information gathering is assessed for each category separately and is defined as the total number of questions asked in any given category. | 5 minutes | 
| Breadth of history taking | Data analysis is performed using video-recordings recorded during scenarios. Trained observers note kind and timing of all questions. The three problem areas chest pain, dyspnea, and leg pain or leg swelling were defined à priori as relevant. Breadth of information gathering is defined as number of relevant problem areas identified (possible range from 0 to 3). | 5 minutes | 
| Systematics of history taking | Data analysis is performed using video-recordings recorded during scenarios. Trained observers note kind and timing of all questions. Questions were categorized in six pre-defined categories (chest pain, dyspnoea,associated symptoms, risk factors for pulmonary embolism,cardiovascular risk factors, personal history). All questions will be rated as either systematic question or non-systematic question. A systematic questions is defined as question, that is either immediately preceded or immediately followed by a question of the same category. Systematic questions will be expressed as percentage of all questions asked during history taking (possible range 0% to 100%) | 5 minutes | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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medical simulation, diagnostic error, pulmonary embolism