Clerking A Simulated Patient aka History Taking

Assalamualaikum wahmatullahi wabarakatuh.

History taking and medical students can't be separated. 70% of the information for doctors to make a diagnosis, or at least to come out with a few differential diagnosis is from history taking. A good history taking. That is what my doctors in Clinical Skills Unit (CSU) always tell us. For every system we will have at least one or two clinical skill sessions on history taking. That is when everyone feels so cuak because masing masing rasa diri tak ready if out of the blue you get a difficult case and a fierce doctor, my god cuak kebebeh I tell you. 

In a group of 8-9 people, each person will have the chance to say something. Some doctors prefer to divide each student to clerk a different component rather than a full history taking, that means one person does the history of presenting illness, another person does the past medical history and so on. While some other doctors might ask a person to do the whole history taking, fuhh! My group is the last group, and like last week, my session was on Thursday. I already asked a friend of mine from the previous group how was her CSU session. And she said the first case was quite hard, and she told me it was about a bladder obstruction because of enlargement of the prostate. And the second case was about a lady, but she didn't tell me what was it and I also didn't ask. 

I went back home and got myself prepared with the first case because usually the first case is always about taking a full history. A friend of mine told me she felt really guilty to herself for not being brave enough to volunteer on her session. Somehow she inspired me to volunteer for my session, so that night before I went to sleep, I told myself, 'No matter how afraid you are or how fierce the doctor is, you must raise your hand and volunteer'. 

Tick tock tick tock. 

After the sister in-charge took our attendance, my group mates and I straight away went to Room 26C and waited for the simulated patient (SP) and the doctor. Doctor A came in and I was like 'Alamak cuaknya she's kind but quite strict'. Then a woman who was our first SP came in. Okay, this is not funny, I thought the first case should be the guy, I'm not ready for this and as usual, I didn't volunteer. 

The doctor chose someone to do the full history taking. She pointed at someone. Guess who?

ME. 

@^$@U@HO*!$Y*@T&*!G#HR*@UE#

*mixed feelings*

I was absolutely not ready for this. I stayed calm, walked to the 'hot seat' and greeted the SP. Dalam hati, Allah je yang tahu. Rasa macam tergolek golek dah jantung jatuh kat lantai haha! 

The patient came with a bilateral swelling on the leg. For HOPI, I asked since when does it start, has this happened before, exacerbating and relieving factors, whether it's pitting or non-pitting, if there's any pain, systems reviews (from head to toe; headache, vomiting, etc.) and I explored the associated symptoms. I asked too much about her urination though (even the urgency, hesitancy, poor stream, dribbling, incontinence) because like I told you, I prepared for the bladder obstruction, not this one haha. Next, I asked more questions about Past Medical History, Drug History, Family History, Diet and Social History. There had been a few questions I'm not really sure I already asked or not, so there was a time, after I asked about the family history, I paused and asked the patient about other symptoms. Amboi sukahati je. I thought I messed up the whole thing. 

Then it was time for the feedback. 

Doctor A asked me how did I feel during the interview. I told her (and also everyone else in that room) that I didn't have any other things in my mind except for fluid retention because of renal failure. I also told her everything was messed up and I think there were questions I wasn't so sure whether I should ask or not.

Doctor A asked the SP how does she feel about me interviewing her. Then she said I was good in term of the voice tone, posture, eye contact, and how I tried to build rapport with her, but one thing, some of the questions I asked were repetitive, which I agreed with that. The doctor also gave feedback. She said everything was smooth, I did quite well, with just an occasional pause, but it wasn't too obvious and can be improved. Then she asked my group mates if they have anything in their minds and most of them told the doctor I did it quite well. Alhamdulillah! 

Then mula lah discuss one by one. The doctor told us there's no such thing as simply ask (which everyone does if tetiba tak tahu nak tanya apa haha). She told us everything must have a reason. To be honest, when you sit on the so-called the 'hot seat', suddenly everything is mixed up and you can't think well compare to when you sit with others. Maybe because everyone is looking at you and listening to what you say attentively kot haha. Doctor A told us that we should actively think to cancel out other causes one by one, like in this case, to cancel CVS causes, respi causes etc. This is where the clinical reasoning plays an important role, and it is one of the main components in history taking (other 2 are communication skills and contents). 

English is not my mother tongue. Although during high school, I was in English Set A for every year, but trust me, I was only good in writing, not in communicating. My friends who were from other sets spoke in English wayyyyy better than me. Yes, I could talk in English, but I preferred not to because my confidence level was at the lowest point.  

But here in IMU, you have to talk in English. Ever since I entered IMU, I always tell myself, I have to improve my communication skills and to do that, I have to brave and confident with myself. Even until now, I am still trying to make myself better and better. 

Here are some tips, which I always do with my friends and might help you in history taking, as a medical student.

1.  Practice with friends. Take turns to become an SP with different cases, so everyone can learn and at the same time can give feedbacks. 

2.  Read more, more and more. Learn how to differentiate one case from another one. 

3.  If you have to interview a simulated patient (SP, not real patients. SP gets a script beforehand and they have to act like a real patient) like us, set your mind you are interviewing a real patient and treat him/her like a real one.

4.  Hard to show empathy? Imagine and put yourself in the patient's shoes and try to really understand how s/he feels. Respond to every concern your SP tells you. Dylla pernah kena marah because tak respond time SP cakap parents dia dah passed away. 

5.  Don't forget to signpost and don't simply jumble up your questions here and there, unless it is really important. Contoh if you think patient punya chief complaint ada kaitan dengan drug, then terus je tanya pasal medication time history of presenting illness (HOPI).

That's all for now. Anyway, I am still a medical student and have not entered clinical school yet so I don't really know how the real challenges look like. I only share things I learned during my clinical sessions and I'm really sorry if it doesn't really helpful at all. Any mistakes I did, just tell me okay. 

Feel free to drop any comments or questions in the comment box below.

Thank you for reading! Assalamualaikum :)