Teaching hypothesis-driven history taking at the bedside: a qualitative study of perspectives, possibilities and precautions

Abstract Background Diagnostic error has a significant impact on patient safety and contributes to harm globally. It is therefore unsurprising that, recently, there has been appreciation that clinical reasoning must be explicitly taught in undergraduate medical training, with diagnostics and clinical reasoning being a key outcome for graduates worldwide. Currently, how best to integrate clinical reasoning into undergraduate medical curricula has not been well explored. This study explores medical students’ perceptions of hypothesis-driven history (HDH) taking in the context of bedside teaching, with the aim of informing when and how such approaches might be optimally introduced. Methods We used a qualitative, constructivist approach to explore medical students’ understanding of HDH, history taking in general, and how it could be taught. A bedside teaching model designed to teach HDH was created and delivered to undergraduate medical students from the University of Glasgow. Focus groups were then conducted, transcribed, and thematically analysed using Braun and Clarke’s approach. Results Two themes, each with three subthemes, were developed. The first theme reflected a re-evaluation of the purpose of history taking, with students describing it as a checklist-driven process of data collection, separate from diagnostic reasoning. The second theme captured the potential for hypothesis-driven history teaching amid pressures and constraints, highlighting both its benefits for clinical reasoning and efficiency, and the cognitive challenges and tensions with assessment expectations that limited its adoption. Conclusions The bedside teaching model challenged students’ preconceptions of history taking, and encouraged re-evaluation of these going forward, consistent with Piaget’s cognitive constructivism. Participants recognised the utility of HDH for clinical practice, but worried about its misalignment with medical school examinations. The cognitive burden expressed by students can be interpreted through the lens of cognitive load theory, particularly with respect to germane load. As such, there are clear perceived benefits of teaching HDH taking to undergraduate medical students, but careful consideration of when and how to implement this teaching is required, needing further research.