Williams Brent C, Ward Denege A, Chick Davoren A, Johnson Eric L, Ross Paula T
a Department of Internal Medicine , University of Michigan Medical School , Ann Arbor , Michigan , USA.
b American College of Physicians , Philadelphia , Pennsylvania , USA.
Teach Learn Med. 2019 Jan-Mar;31(1):87-98. doi: 10.1080/10401334.2018.1480958. Epub 2018 Sep 14.
The traditional approach to physicians' history taking is designed to facilitate diagnosis and treatment of biomedical conditions. However, in the 21st century, health is critically influenced by the interaction of biomedical conditions and nonbiomedical factors such as patient's ability to manage chronic disease and the social determinants of health. Interventions to expand routine history taking to include nonbiomedical factors have not been widely adopted, possibly due to the difficultly of incorporating long checklists into routine care and the inability to achieve consensus on the relevant behavioral or social determinants of health content applicable to all patients.
In 2015-2016, we introduced medical students to a 6-domain (biomedical and psychiatric conditions, behavioral health, living environment/resources, social support, and functional status) approach to history taking and instructed them to elicit information from each domain alongside the traditional approach. Students were required to obtain information from each domain in one admitting history or one daily progress note, discuss their findings with the attending physician, and involve members of the medical team in addressing concerns and barriers in the care of that patient. Students' history notes were reviewed for completeness and compared to those from a student control group. Students also completed a 10-question evaluation of the model.
The intervention was conducted during a 1-month rotation on a hospitalist general medicine service from May 2015 through August 2016.
Patient history and daily progress notes were collected from 38 fourth-year intervention students and compared to 24 control students on the same service from the previous year. Compared to control students, intervention students provided more patient information (p ≤ .001) in all nonbiomedical domains except behavioral health. Intervention students reported that the 6-domain model helped them identify clinical information that could be addressed with existing resources and prompted involvement of social workers, pharmacists, and nurses in care planning. They also indicated the framework added clinically valuable information and enhanced team-based care.
A domain-based framework can be used by medical students to identify clinically relevant behavioral conditions and social determinants of health tailored to individual patients while avoiding long standardized checklists. Arguably, routine collection of behavioral and social determinants of health is a necessary first step in enhancing physicians' awareness and skills in working with health care teams to address nonbiomedical determinants of patients' health.
传统的医生问诊方法旨在促进生物医学疾病的诊断和治疗。然而，在21世纪，健康受到生物医学状况与非生物医学因素相互作用的严重影响，如患者管理慢性病的能力以及健康的社会决定因素。将常规问诊扩展到包括非生物医学因素的干预措施尚未得到广泛采用，这可能是由于难以将冗长的清单纳入常规护理，以及无法就适用于所有患者的相关健康行为或社会决定因素内容达成共识。
在2015年至2016年期间，我们向医学生介绍了一种涵盖6个领域（生物医学和精神疾病状况、行为健康、生活环境/资源、社会支持和功能状态）的问诊方法，并指导他们在采用传统方法的同时从每个领域获取信息。要求学生在一份入院病史或一份每日病程记录中从每个领域获取信息，与主治医生讨论他们的发现，并让医疗团队成员参与解决该患者护理中的问题和障碍。对学生的病史记录进行完整性审查，并与学生对照组的记录进行比较。学生们还完成了对该模型的10道问题评估。
该干预措施于2015年5月至2016年8月在医院内科普通病房进行了为期1个月的轮转期间实施。
收集了38名参与干预的四年级学生的患者病史和每日病程记录，并与上一年同一病房的24名对照学生的记录进行比较。与对照学生相比，参与干预的学生在除行为健康外的所有非生物医学领域提供了更多患者信息（p≤0.001）。参与干预的学生报告说，6领域模型帮助他们识别可以利用现有资源解决的临床信息，并促使社会工作者、药剂师和护士参与护理计划。他们还指出，该框架增加了具有临床价值的信息，并加强了团队协作式护理。
医学生可以使用基于领域的框架来识别针对个体患者的临床相关行为状况和健康的社会决定因素，同时避免使用冗长的标准化清单。可以说，常规收集健康的行为和社会决定因素是提高医生在与医疗团队合作以解决患者健康的非生物医学决定因素方面的意识和技能的必要第一步。
