Aprender a preguntar: un recurso didáctico para el aprendizaje de la anamnesis médica / Learning to ask: a teaching resource for learning medical anamnesis

RESUMEN Introducción: La anamnesis médica es el proceso de comunicación interactiva entre el médico, el paciente, su familia o ambos, con el propósito de identificar y caracterizar los síntomas que expresan la realidad del estado de salud del paciente, para establecer el diagnóstico y la intervención médica. Objetivo: Diseñar un sistema de acciones didácticas que faciliten a los estudiantes de la carrera de Medicina el aprendizaje de la anamnesis. Método: En el Hospital General Docente "Dr. Agostinho Neto" se desarrolló un estudio de tipo pedagógico con dicho objetivo, donde se utilizaron los métodos: histórico- lógico, análisis y síntesis e inducción-deducción. Se empleó, además, la modelación para la elaboración del modelo de preguntas y el enfoque sistémico para determinar su estructura y establecer las relaciones entre ellas. Resultados: El empleo de procedimientos (trasmisión de experiencias, ejemplos prácticos, modelos memorísticos basados en la imitación), sin un sustrato teórico estructurado, dificulta la aplicación plena de los contenidos médicos en pacientes concretos en condiciones reales semejantes o diferentes a las aprendidas, lo que constituye una limitación para la formación de esta habilidad en la asignatura Propedéutica Clínica y Semiología Médica. Conclusiones: Se ofrece un modelo de aprendizaje por preguntas, con el cual se dota al estudiante de un recurso didáctico-metodológico para la comunicación interactiva con el paciente, lo que facilita el aprendizaje de la escucha activa y la comprensión del paciente por el estudiante. Contribuye, además, con la calidad de la confección de la historia clínica.

ABSTRACT Introduction: Medical anamnesis is the process of interactive communication between the physician, the patient, his or her family, or both, for the purpose of identifying and characterizing the symptoms that express the reality of the patient's state of health, in order to establish the diagnosis and medical intervention. Objective: To design a system of didactic actions that will make it easier for medical students to learn the anamnesis. Method: At the General Teaching Hospital "Dr. Agostinho Neto" a pedagogical study was developed with this objective, where the methods used were: historical-logical, analysis and synthesis and induction-deduction. In addition, a modeling was used to develop the question model and the systemic approach to determine its structure and establish the relationships between them. Results: The use of procedures (transmission of experiences, practical examples, memory models based on imitation), without a structured theoretical support, makes it difficult to fully apply the medical content to specific patients in real conditions similar to or different from those learned, which constitutes a limitation for the training of this skill in the subject Clinical Propedeutics and Medical Semiology. Conclusions: A question-based learning model is offered, in which the student is equipped with a didactic-methodological resource for interactive communication with the patient, which facilitates the learning of active listening and the understanding of the patient by the student. It also contributes to the quality of the preparation of the clinical record.

La relación médico-paciente: ¿necesidad o conveniencia? / The doctor-patient relationship: need or convenience?

Se destaca la relación médico-paciente como un modelo singular de comunicación humana, el cual sirve de marco a la interacción intelectual y afectiva más importante de la práctica clínica: la que se lleva a cabo a través de la entrevista médica. Esta es herramienta fundamental para obtener una anamnesis fidedigna y establecer una relación médico-paciente sólida, perdurable y productiva, pues la habilidad para comunicarse eficientemente no solo consiste en saber expresarse, sino, sobre todo, en saber escuchar, con lo cual se comienza a cumplimentar el primer principio del método clínico, que es el de la profesión médica. El objetivo de esta investigación fue actualizar los conocimientos acerca de la relación médico-paciente de acuerdo con el método clínico. Para ello, se revisaron las contribuciones teóricas realizadas por prestigiosos internistas cubanos a lo largo de la historia, unidas a las posiciones asumidas por las presentes autoras a partir de sus propias experiencias. Sin dudas, el logro de una relación médico-paciente exitosa deviene una poderosa arma para el diagnóstico certero(AU)

The doctor-patient relationship stands out as a unique model of human communication, which serves as a framework for the most important intellectual and affective interaction of clinical practice, which is carried out through the medical interview. This is a fundamental tool to obtain reliable history and establish solid, lasting and productive doctor-patient relationship, since the ability to communicate efficiently is not only knowing how to express oneself, but also, and above all, knowing how to listen, which begins to complete the first principle of the clinical method, which is that of the medical profession. The objective of this research was to update the knowledge on the doctor-patient relationship according to the clinical method. To this end, we reviewed theoretical contributions made by prestigious Cuban internists throughout history, together with the positions assumed by the present authors based on their own experiences. Certainly, the achievement of a successful doctor-patient relationship becomes a powerful weapon for accurate diagnosis(AU)

Students in medical interview training classes prefer the teacher's feedback, including stories of their clinical experiences, and discussion among students / 医学教育

<p>Objective: Teachers of various departments are in charge of medical interview training classes with the participation of simulated patients. However, it is not clear whether there are differences in feedback (FB) among teachers. The objective was to examine differences in FB among teachers, investigate effective FB methods, and evaluate the effect of an FB manual.<br>Methods: We conducted a questionnaire survey of students to assess their evaluation of FB by teachers. In the meantime, we transcribed and analyzed teachers' FB on the basis of video recordings. We created a teacher's manual for FB on the basis of these results. We conducted a similar survey the following year.<br>Results: The evaluations from students included many positive opinions, such as "we heard from the teachers about their clinical experiences" . Analysis of the videos showed significant differences in the contents of FB among groups. The performance of the interview strongly influenced the content of the FB. Variations in each group tended to be reduced the following year.<br>Conclusions: 1) There were significant differences in FB among teachers. 2) FB that includes the clinical experiences of the teacher and discussion among students may enhance the learning effect. 3) Introduction of the manual increased the relevance of FB.</p>

What are the benefits of simulation training with simulated patients? / 医学教育

Introduction: Consultation simulation with simulated patients has rarely been done as a training program.<br>Method: Fifth-year medical students in 2 neighboring universities attended the same training program at each site. The students’ performance was evaluated.<br>Result: Most medical students thought that this training program was valuable and that they require more opportunity to practice. Students evaluated their own performance in both medical procedures and differential diagnosis as being poor. However, about 50% of students felt that they paid careful attention to the simulated patient during physical examination. Students thought that the consultation was extremely realistic and that the series of medical procedures they performed at the first attempt was extremely difficult but increased their motivation. They thought that the feedback they received from simulated patients was beneficial.<br>Discussion: This education program is highly regarded by students and is suggested to be versatile.

Effects of the Objective Structured Clinical Examination-Reflection Method: / 医学教育

Background: The Objective Structured Clinical Examination （OSCE）–Reflection Method （OSCE-R）, a version of the OSCE for training physical therapists which incorporates group reflection through video, has been developed and implemented in our study. The purpose of this research was to introduce the OSCE-R to the second-year students and to examine its effects on learning.<br>Method: The subjects were 91 second-year students of the physical therapy department of our university. Before and after group reflection, OSCE score comparison, reflection sheet analysis, a questionnaire survey, and interview investigation were performed.<br>Results and Discussion: The OSCE scores increased significantly, and students learned the importance of reflection and empathy with patients. The combination of theory and clinical practice helped students to actively learn while crossing boundaries between school and hospital.

Qualitative research on outpatients' explanatory models / 日本プライマリ・ケア連合学会誌

<b><i>Abstract</i></b><br><b>Introduction</b> : The purpose of this study was to identify the function of outpatients' explanatory models by qualitative research.<br><b>Methods</b> : Medical records of ninety one patients from our department were investigated from 1st September 2011 to 28th February 2012 inclusive, and were analyzed by the modified grounded theory approach.<br><b>Results</b> : The explanatory models were categorized into three groups according to their narrative, which included the following : Diagnostic model, Pathological model and Psycho-social model. Patients in the psycho-social model had no organic diseases except one pneumonia case. In the other two models, one half of the patients had organic diseases. However, the patients' self-diagnoses were frequently incorrect. We considered that their diagnostically incorrect narratives contained potential hidden messages. We therefore generated an hypothesis that patients projected their cognitive images onto the diseases they suspected.<br><b>Conclusion</b> : We consider that a patient's self-diagnosis, such as cancer or cerebral infarction, appears to contain both medical information and a metaphorical message. Further investigation is needed to understand the meaning of such hidden messages.

Decision Tree Analysis of 100 Types of Body Constitution as Factors of Adverse Drug Reaction / 医薬品情報学

<b>Objective: </b>In this study, we evaluated distinctive types of physical predisposition in patients with common side effects.<br><b>Method: </b>We selected 500 and 1,200 individuals with and without a previous diagnosis of side effects, respectively, through web-based research.  Then, we conducted a decision tree analysis for investigating the status of 100 types of physical predisposition in these individuals.<br><b>Results and Conclusion: </b>The individuals who had suffered from hepatic disorder and answered “relevant” for “predisposition to swelling” (likelihood ratio of a positive result [LR+] 2.17; <i>p</i>=0.004) and “very relevant” for “predisposition to skin dryness” (LR+ 3.52; <i>p</i><0.001) enhanced the probability of extracting individuals who developed side effects.  The individuals who had suffered from skin disorder and answered “relevant” for “predisposition to eczema and inflammation” and “not relevant” for “predisposition to higher temperature” had an LR+ of 2.22 (<i>p</i><0.001).  The individuals with “predisposition to worsening of physical condition on a rainy or high-humidity day” are more likely to develop side effects with the use of antibiotics and NSAIDs, compared to those without this predisposition (antibiotics: LR+ 2.33; NSAIDs: LR+ 2.51).  The results of this study indicate that we can identify patients with a high risk of side effects through an interview on predisposition.

Habilidades comunicativas para la relación médico paciente en estudiantes de Medicina desde la percepción de profesores / Communication skills for the physician-patient relationship in medical students, according to the professors' perception

El presente trabajo aborda la percepción que tienen profesores seleccionados con experiencia, categoría docente principal, de investigador y/o grado científico del área clínica de las universidades médicas de Matanzas , Pinar del Río y La Habana, que realizan su labor profesoral en la enseñanza de las Ciencias Clínicas con el objetivo de valorar el desarrollo de las habilidades comunicativas de los educandos, a partir de la percepción que tienen esos profesores del cumplimiento de las funciones de la comunicación para una adecuada relación médico paciente. Se aplica una encuesta que indaga los criterios que poseen los profesores sobre el desarrollo de las habilidades comunicativas en los estudiantes. Las habilidades tenidas en cuenta son las necesarias para realizar el interrogatorio y el examen físico como parte del método clínico. Las encuestas fueron procesadas a través del software SPSS y se determinó que eran confiables y válidas. Los resultados reflejan criterios generalizados de insuficiente desarrollo de habilidades en los estudiantes para lograr el cumplimiento de las funciones reconocidas en ellas. Se evidenció la necesidad de seguir profundizando en este tema y que es una necesidad elaborar estrategias para el desarrollo de las habilidades comunicativas, imprescindibles en la formación médica a la que se aspira

This article was aimed at assessing the development of communication skills in students on the basis of the criteria of selected experienced professors about the functions of communications for adequate physician-patient relationship. These educators held different categories such as assistant professor, researcher and/or scientific degree in the clinical area of the medical schools located in Matanzas, Pinar del Rio and La Habana and taught clinical sciences. The surveys looked for the criteria of these professors about the development of communication skills in students, which are taken into account for questioning and for physical examination of the patient as part of the clinical method. They were processed by SPSS software and their reliability and validity were confirmed. The results showed the general opinions about the poor development of skills in students to duly fulfill these functions. It was concluded that there is a need of delving into this topic and of designing strategies to support the acquisition of communication skills that are so indispensable in the medical formation at present

Propuesta de guía metodológica para evaluar las habilidades comunicativas en la entrevista médica / Proposal of methodological guideline to evaluate the communication skills in the medical interview

En nuestra práctica médica docente no existen orientaciones metodológicas específicas que se concreten en un instrumento evaluativo de habilidades comunicativas de valor principalmente formativo y que asuma el criterio de evaluación por tendencias. Objetivo: desarrollar una guía metodológica para evaluar, bajo observación directa, el desarrollo de las habilidades comunicativas. Métodos: se realizó una encuesta a 13 profesores de Medicina Interna, en el Hospital Militar Central Dr Carlos J Finlay con vistas a conocer sus criterio sobre una guía metodológica de evaluación de habilidades comunicativas. Resultados: se efectuaron las modificaciones sugeridas en cuanto a los componentes de las habilidades para expresar y hubo aceptación de la evaluación por tendencias. Conclusiones: la guía metodológica presentada tiene mayor validez de contenido al incluir nuevos aspectos que reflejan mejor el constructo cognitivo y conductual del médico durante la entrevista a pacientes. La validez funcional de la guía es superior al lograr mejor orden en las habilidades de expresión, mayor claridad en el enunciado de habilidades y de la aplicación del enfoque de evaluación por tendencias

Our medical and teaching practice lacks specific methodological instructions that materialize in an evaluative instrument of communication skills, of formative value fundamentally, to assume the evaluative criteria by tendencies. Objective: to develop a methodological guideline for evaluating the development of communication skills under direct observation. Methods: surveys administered to 13 internal medicine professors, who worked at Carlos J Finlay central military hospital, with a view to finding out their opinions on an evaluative methodological guideline for communication skills. Results: the suggested changes were made in terms of elements of expressive skills and the idea of evaluation by tendencies was accepted Conclusions: the submitted methodological guideline has more validity in contents since it covers new aspects that better reflect the cognitive and behavioral construct of physician in the course of interviews to patients. The functional validity of the guideline is greater as it succeeds in attaining better order of expressive skills, more clarification in the enunciation of skills and better implementation of the evaluation by tendency approach

Training Curriculum for Simulated and Standardized Patients: The 16th Medical Simulation Committee of the Japan Society for Medical Educatio / 医学教育

1．The basic training curriculum for simulated and standardized patients （SPs） was provided by the 16th Medical Simulation Committee based upon a nationwide field survey that was conducted by the committee in 2009 and other data.<br>2．The curriculum consists of 3 essential programs: interpersonal communication, medical education involving SPs, and the medical interview.<br>3．The medical interview program was composed of basic issues, comprehension of scenarios, acting role and performance, and feedback and assessment.<br>4．The training facilities or institutions were recommended to properly assess the performance quality of SPs in the educational setting by means of a specific and clearly defined evaluation method.

Recurso semiotécnico para otimizar o desempenho de estudantes em consultas de puericultura: uma experiência piloto / Optimization of students' performance in child care consultations through a semiotic resource: a pilot experience

Este trabalho descreve e comenta uma experiência piloto de ensino de semiologia pediátrica em Unidades de Saúde da Família, através do uso de fluxogramas individualizados por idade, de acordo com a rotina do Ministério da Saúde para acompanhamento durante o primeiro ano de vida. O estudo foi realizado durante atendimento pediátrico inserido no módulo Piesc III para alunos do terceiro ano de Medicina da Universidade Estadual de Feira de Santana - Bahia (UEFS). Os fluxogramas foram aplicados em campo, mostrando-se efetivos para a sistematização das consultas de puericultura na etapa em que os estudantes se encontravam, reduzindo o estresse inicial, proporcionando maior segurança aos alunos e possibilitando anamneses mais extensas e esclarecedoras, com repercussão no aprendizado dos alunos e possibilidade de melhoria na qualidade da assistência às crianças e na oferta de dados em prontuários para pesquisa.

This paper describes and comments on a pilot teaching experience in clinical pediatrics in Family Health Units, using individualized flowcharts by age, according to the Brazilian Ministry of Health's guidelines for monitoring infants (0-12 months of age). The study was performed during pediatric care as part of training for third-year medical students at the State University in Feira de Santana, Bahia (UEFS). The flowcharts were applied in the field and proved effective for systematizing child care consultations at the students' respective stage of development, reducing the initial stress, providing greater security for students, and allowing more extensive and instructive case histories, with positive repercussions on the students' learning and the possibility for improved quality of care for children and recording of relevant data on patient charts, for use in future research.

Examination of reliability in assessing medical interviews in acupuncture and moxibustion training institutes / 医学教育

Our institution has introduced the objective structured clinical examination as a means of objectively assessing the learning status of students. An annual task is to increase the reliability of assessment tables at medical interview stations. To increase the reliability of assessment tables, it might be necessary to increase the concordance among assessors. Thus, we examined the reproducibility of the assessment items.<br>1)With the cooperation of 4 training institutes for acupuncture and moxa cautery, medical interview examinations by 89 students were videotaped after they had heard a lecture on medical interviews, had been provided with information about the examination, and had given consent.<br>2)We asked 6 institute members with experience in assessing medical interview examinations to assess the same recorded videotaped interviews individually and in pairs. We asked them to assess the same video again after a certain period of time.<br>3)High concordance was observed for every item by single assessors but not for many items among assessors.<br>4)Single–assessor concordance was not necessarily correlated with that among assessors.<br>5)When agreement was not expected in advance, the assessors performed assessments on the basis of their own educational criteria, which may result in decreased concordance among assessors.

Performance of the curriculum for communication skills for breaking bad news: Evaluation with Common Achievement Tests OSCE and advanced OSCE / 医学教育

Skills for breaking bad news (BBN) at the medical interview station were evaluated with the advanced objective structured clinical examination (OSCE). To clarify performances at this station, we compared the scores at this station with those of the Common Achievement Tests OSCE controlled by the Common Achievements Test Organization (CATO). The subjects were a group of students tested at an interval of 1 year 4 months during their clinical clerkships.1) Raters (mostly postdoctorate fellows) played simulated patients after they had been trained to ensure standardization.2) Students who had high scores for BBN skills on the advanced OSCE also had high scores for both the behavior part and the knowledge part of the total evaluation.3) In contrast, students who had high scores for BBN skills on the advanced OSCE did not always have high scores on the Common Achievement Tests OSCE, suggesting the importance of clinical clerkships between these 2 OSCEs.

A Study of the Evaluation of Information-Gathering Capability in the Pharmaceutical Objective Structured Clinical Examination / 医学教育

In the medical interview portion of the objective structured clinical examination (OSCE), we usually use both detailed checklists and a global rating scale to evaluate a student's performance. In the present study we investigated a problem with the detailed checklists.<br>1) The quality of the assessment of information-gathering capability was investigated in a station for the medical interview in a pharmaceutical OSCE.<br>2)A video review revealed a 7% error in the detailed checklist assessment at the OSCE station.<br>3) Following the interview in this study, the students wrote down the information they had gathered. These results differed by 15.6% from those of the detailed checklist assessment at the OSCE station. <br>4) In the present style of OSCE, the detailed checklist assessment at the OSCE station is problematic. The style in which the students write down the gathered information after the interview might be re-considered.

A Method to Assessing Empathetic Attitudes / 医学教育

1) Empathy is a psychological phenomenon that cannot be observed from the outside. The Japanese word kyokan is used to mean both "empathy" and "sympathy" in English. Therefore, instruction in and assessment of empathy are difficult and involve confusion.<br>2) In the "dialogue method" proposed in this paper, the responses of the medical care staff are divided into "confirmative responses" and "reactive responses." Instruction with this method contributes to the improvement of medical communication skills.<br>3) The effect of a "confirmative response" is similar to that of empathy. If attention is paid to these verbal communication skills, empathy can be assessed as an observable skill.

Effects of Medical Student Gender on Communication during Objective Structured Clinical Examination Medical Interviews / 医学教育

This study aimed to assess how the gender of medical students affects their communication styles and those of simulated patients (SPs) during objective structured clinical examination medical interviews in Japan. <br>1) Medical interviews conducted by 82 fourth-year medical students (53 male and 29 female) at Nagoya University School of Medicine were analyzed by means of the Roter Interaction Analysis System.<br>2) Compared with male medical students, female medical students engaged in significantly more emotionally focused talk, particularly empathy, and asked more open-ended questions. <br>3) With female medical students, SPs engaged in significantly more social talk (personal remarks), gave more biomedical information, and made more total utterances than they did with male medical students.<br>4) The gender of medical students significantly affected their communication styles and those of SPs. (127 words)

Medical Interview Skills and Patient Satisfaction Levels in a Setting Utilizing Electronic Medical Records / General Medicine

<b>BACKGROUND</b> : Electronic medical records (EMRs) were first introduced in the 1960s, and in Japan they are starting to become popular. Recognizing the need to adapt to a new clinical setting with EMRs, we aimed to explore which interviewing skills were associated with patient satisfaction in this era of EMR use.<br><b>METHODS</b> : A prospective observational study was conducted to evaluate interviewing skills among medical residents and to collate data on patients' satisfaction levels at an outpatient general medicine walk-in clinic at a teaching hospital in Japan. Five trained raters reviewed the video recordings of these interviews and assessed them based on a predetermined set of criteria for medical interview skills developed specifically for an outpatient EMR setting. The relationships between these assessment scores and patient satisfaction levels were analyzed.<br><b>RESULTS</b> : Significant skills that were associated with higher scores of patient satisfaction included : employed appropriate eye contact (P=0.021) ; and, invited patients directly without using a microphone (P=0.008). In addition, the degree of keyboard typing during interviews was not associated with patient satisfaction.<br><b>CONCLUSIONS</b> : In an outpatient setting with EMR, using good non-verbal communication skills to build trustful relationships with patients is more likely to influence patient satisfaction levels. Even when physicians are typing on a keyboard, if they keep appropriate eye contact during medical interviews, patient satisfaction can be improved.

Las habilidades comunicativas en la entrevista médica / Communicative skills during the medical interview

Las habilidades comunicativas son imprescindibles para establecer una relación médico-paciente satisfactoria y obtener la información para llegar a un diagnóstico correcto, de ahí la importancia de comunicarse con habilidad con el paciente. En el presente trabajo se propusieron adaptar las habilidades comunicativas utilizadas en el ámbito pedagógico al contexto del interrogatorio médico. Estas se agruparon en: habilidades para expresar, habilidades para observar y escuchar, y habilidades para establecer una relación empática. De cada grupo se expresaron sus componentes, así como el significado de cada uno como habilidad. Se concluye que al ser la comunicación una actividad esencial en las relaciones humanas y por tener un carácter de invariante esencial, las habilidades comunicativas definidas por la pedagoga Ana María Fernández González para la comunicación profesor-estudiante, se pueden adaptar al contexto del interrogatorio médico.

Communication abilities are essential to establish a satisfactory physician-patient relation ant to obtain information to made a appropriate diagnosis, hence the significance to achieve a skilful communication with the patient. In present our aim was to adapt the communication abilities used in educational scope to the medical questioning context. These are grouped in: expression abilities watch and heed abilities, and abilities to establish an empathy relation. From each group its components were expressed, as well as the meaning of each as ability. We conclude that communication is an essential activity in human relations and by its significant character, communication abilities, defined by the educator Ana María Fernández González in case of professor-student communication, may be adapted to medical questioning context.

La entrevista terapéutica / The therapeutic interview

La entrevista médica es la herramienta fundamental para obtener una anamnesis fidedigna y para establecer una relación médico-paciente sólida, perdurable y productiva. La habilidad para conducirla puede ser aprendida, perfeccionada y cultivada mediante el estudio, la práctica y la auto-observación. Una entrevista tiene valor terapéutico cuando el enfermo encuentra en el médico capacidades de respeto, interés, autenticidad, coherencia y comprensión empática. La anamnesis es un proceso dinámico que consiste en etapas sucesivas y diferentes entre sí. En cada una de estas etapas pueden conseguir aciertos o cometerse errores por acción o por omisión, los cuales influyen en forma decisiva en su curso ulterior y eventualmente en su éxito o en su fracaso. Se describe un esquema posible en el que la entrevista consta de cinco etapas, en cada una de las cuales la actitud y capacidad del médico son importantes para guiar al enfermo y ayudarlo a producir información. Se presentan y analizan aquellos factores que facilitan o dificultan que una entrevista tenga valor terapéutico.

The medical interview is a fundamental tool to obtain a trustable clinical history, and also to establish a productive, strong and long standing relationship with the patient. The ability to guide an interview can be learned and cultivated through study, practice and self-observation. An interview has therapeutic value when the patient finds in the physician qualities such as interest, respect, coherence, authenticity and an empathic response. The interview is a dynamic process consisting in successive and different stages. A tentative scheme is described for the therapeutic interview consisting in five stages, in all of which the attitude and capacity of the physician are important in guiding the patient and helping to produce valuable information.

The significance and problems of medical interview training with standardized patients in clinical training after objective structured clinical examinations / 医学教育

1) To examine the significance and problems of medical interview training, self-administered questionnaires were completed by 90 students who took part in medical interview training with simulated patients in clinical training after objective structured clinical examinations.2) Most students thought that medical interview training was meaningful and thanked the simulated patients for their useful comments. On the other hand, some students felt that to improve their interviewing skills stricter feedback from simulated patients and instructors might be needed.3) Our results suggest that repeated training in medical interviewing in clinical training after objective structured clinical examinations is an effective method for teaching communication skills. However, in the future the scenarios should be improved and the frequency of medical interview training should be increased.