Dare Anna J, Cardinal Alexandra, Kolbe John, Bagg Warwick
Medical Programme, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland 1142, New Zealand.
N Z Med J. 2008 Sep 22;121(1282):51-7.
History-taking is one of the most important clinical skills for the medical student to learn and remains the core component of a doctor's diagnostic 'toolkit'. Yet, it is one of the most difficult clinical skills to assess. Clinical assessment at a trainee intern level has typically focussed on examination skills, and case presentation, which are more easily measured. History-taking is assumed to be of an adequate standard on the basis of the case presentation rather than by direct observation. In this paper we discuss the importance of assessing the patient-doctor encounter directly through observation, in the context of the trainee intern long case examination. Despite changing assessment trends in medical education, these authors argue for the retention of the long case as an assessment tool for final year medical students on the basis of its high face validity and close resemblance to "real life" patient encounters. However, we believe addition of an observing examiner during the history-taking and physical examination augments the inherent value of the longcase and is recommended in order to increase the reliability of the assessment. Observation allows for direct assessment of the student-patient interaction and the hypothetico-deductive approach taken by the student to diagnosis. It provides opportunity to reconcile the multiple interactions occurring between the context and the construct (skills and knowledge) measured in an assessment. Importantly, at a trainee intern level it provides students with a final opportunity to receive feedback on their history taking and diagnostic skills, an integral part of all medical practice, prior to their graduation as junior doctors.
病史采集是医学生需要学习的最重要的临床技能之一，并且仍然是医生诊断“工具包”的核心组成部分。然而，它是最难评估的临床技能之一。实习医生水平的临床评估通常侧重于更容易衡量的检查技能和病例汇报。病史采集被认为基于病例汇报而非直接观察达到了足够的标准。在本文中，我们在实习医生长病例考试的背景下，讨论通过观察直接评估医患互动的重要性。尽管医学教育中的评估趋势不断变化，但这些作者基于长病例的高表面效度以及与“现实生活”中患者诊疗过程的高度相似性，主张保留长病例作为医学专业最后一年学生的评估工具。然而，我们认为在病史采集和体格检查过程中增加一名观察考官会增加长病例的内在价值，并且为了提高评估的可靠性而推荐这样做。观察能够直接评估学生与患者的互动以及学生采用的假设 - 演绎诊断方法。它提供了一个机会来协调在评估中情境与所测量的结构（技能和知识）之间发生的多种相互作用。重要的是，在实习医生阶段，它为学生提供了一个在毕业成为初级医生之前，就其病史采集和诊断技能获得反馈的最后机会，而这些技能是所有医疗实践不可或缺的一部分。
