A Structured Approach to History and Physical Examination in Oncology for Medical Learners

Abstract

In oncology, traditional H&P templates centered on a single chief complaint often fail to address the longitudinal care needs and emotional complexities of cancer patients, leaving learners unprepared for sensitive conversations such as breaking bad news or discussing treatment goals. To address this, we conducted a literature review of specialty-focused H&P tools in child psychiatry and gynecology and, drawing on our experiences as two first-year medical students in an outpatient oncology clinic, developed an oncology H&P template to guide novice clinicians. The guide incorporates structured prompts for rapport-building; detailed oncologic and family cancer history; functional independence assessments; treatment goals; emotional wellbeing; support networks; and responding to emotion. After initial pilot testing by the two developers under supervisor guidance, the template was distributed to five then ten additional students and disseminated via the ASCO online forum and Twitter. Feedback from ten oncologists and oncology trainees highlighted the template’s value in gathering review of systems, past treatment details, functional status, and cancer history. Our findings suggest that this oncology-tailored tool enhances interview flow, promotes comprehensive data collection, and supports empathetic patient engagement. Integration into routine oncology training is planned, with future adaptations for specific oncological subspecialties and potential use in other medical specialties.

1. Introduction

Students in health disciplines are traditionally taught history and physical (H&P) skills using templates [1]. These include the mnemonic OPQRSTU for a focused, chief- complaint history [2] and DRUGS for medication and drug history [3].

While helpful for more junior learners, these standard H&Ps lack nuances specific to certain specialties, such as oncology, which may not revolve around acute medical ailments or general well-visits. Given their focus on the overarching human experience, complex conditions, and longitudinal care, oncology rotations (and other fields such as palliative care and psychiatry) provide challenges for students who have been trained for acute, one-issue H&Ps, such as the OPQRST model [4,5]. Indeed, as the complexity of patients increases with advances in medical care, one-issue H&P templates may become increasingly restricting for the novice medical learner.

A systematic review by Keifenheim et al. [1] identified different ways of teaching H&P to medical students, including role-play and interviews with real patients, followed by feedback and discussion. This review highlights the importance of focusing on thorough history-taking to arrive at the correct diagnosis. However, guidance is needed for novice medical providers who are still learning to be comfortable with clinical assessments. Neeley et al. [6] surveyed medical students across the United States on their perspectives of oncology curricula in their medical students. This article identified an under-emphasis in medical education to fields of oncology, in addition to highlighting variability in how history-taking is taught in the oncology setting. While individual medical providers have unique styles that vary across oncology subspecialties, it is helpful for a novice learner to follow a series of questions that can later be developed into their own interview format.

Guidelines outlining oncology-focused history and physical exam for advanced practice providers focus on the initial important history for a patient with a new diagnosis of cancer [7]. Rosenzweig et al. [7] recommends using national guidelines to inform diagnostic workup and gather relevant information for the tumor type, obtaining relevant cancer-focused history, performing the physical exam, and organizing the data for proper presentation and documentation. The recommendations provided are certainly helpful for advanced practitioners and can certainly be used by medical students. However, when specialized scripts have been made for other fields with unique history and physical exams, such as child psychiatry and gynecology, the structured interview was found to be particularly effective in helping novice learners navigate inherently difficult, complex cases to obtain relevant information and accurate diagnoses [8,9]. To best assist medical students, we sought to develop an H&P template that includes phrases to obtain relevant medical information and ensure empathy to help structure the learners’ history.

2. Materials and Methods

This project is a quality improvement project developed by two medical students and a medical oncologist through experience in an oncology clinic.

The template was first developed by two medical students after rotating once weekly in an outpatient oncology setting for 6 months, with input from the supervising medical oncologist. The students first identified the gaps in the history when using a standard, chief complaint focused history. These included values in life, goals of treatment, understanding of present illness, family oncological history and genetic testing, and functional independence. Then, history questions were written to address these gaps and produce the first iteration of the guiding questions. This draft was reviewed by the supervising medical oncologist before being used in an outpatient oncology clinic.

After being used and implemented by the two medical students for 2 months, the model underwent three rounds of iterative feedback with subsequent edits to the template (Figure 1). All feedback was open-ended and voluntary. A formal survey or analysis tool to evaluate the template was not used, as this was a Quality Improvement initiative. The script was shared with four medical students all in oncology practices, who provided their narrative feedback in-person and via e-mail. After edits based on this feedback, the template was finally shared to an online forum on the America Society of Clinical Oncology (ASCO) and via the social media platform X (Twitter), and edited again based on the suggestions online.

3. Results

Feedback highlighted the strengths of the template, including the utility of the template (See Appendix A). Many students found the H&P template helpful, especially sections on review of systems (ROS), past treatments, functional independence, and cancer history. These areas helped guide focused patient conversations, which differ significantly from other clinical settings. Students reported that the template helped guide patient interviews, reduce cognitive overload during complex visits, and encourage more holistic, empathetic conversations. Specific sections noted as especially helpful included prompts for functional status, review of prior treatments, and support systems. Students also highlighted the value of having scripted phrasing for emotionally sensitive encounters, such as discussing goals of care or addressing fear and uncertainty. Based on feedback, revisions included clarifying prompts, incorporating follow-up visit adaptations, and expanding side effect review questions.

Clinical educators mentioned the template’s strength in preparing medical students for patient encounters by providing valuable context, such as the importance of discussing treatment values and goals, which many learners had not encountered before. Finally, reviewers praised the guide as a useful introductory tool for junior learners that effectively balances the complexities of oncology care.

Reviewers offered several suggestions to enhance the guide. Adding more specific prompts about past treatments and their potential side effects, such as dry mouth or skin changes, was recommended to ensure comprehensive patient evaluations. Dividing the template into sections tailored for new and return visits was another suggestion, though some expressed concerns that this could introduce unnecessary complexity. Including questions about short-term treatment goals, such as next steps in therapy over the coming weeks or months, was proposed and implemented to complement existing prompts on life values and long-term goals.

Several medical educators expressed strong interest in utilizing the guide in their teaching, including a third- and fourth-year elective. They encouraged publication to allow broader implementation and integration into medical education.

4. Discussion

This oncology-specific guide for medical students has significant potential to enhance the quality of education and patient care in oncology settings. By providing a structured H&P template and detailed prompts, the guide equips learners with tools to navigate complex patient encounters, fostering a more patient-centered approach.

The inclusion of tailored questions about treatment history, side effects, and functional goals allows students to develop a deeper understanding of the unique needs of oncology patients, while the focus on treatment priorities and short-term goals ensures meaningful conversations that align with patients’ priorities. The guide also prepares students to address nuanced considerations that are critical to comprehensive cancer care, such as balancing comorbidities and treatment side effects. The template questions can be further modified and expanded to fit oncologic subspecialties, particularly regarding specific cancer course and symptoms, treatments for a specific cancer, and common side effects associated with those treatments.

Beyond individual encounters, this guide has broader implications for medical education. It serves as a foundation for improving competency in oncology across various levels of training and could be adapted for use in clerkships, electives, and interprofessional settings. Educators have already expressed interest in incorporating the guide into their curricula, demonstrating its potential for widespread adoption both within and outside of oncology. This template could inspire the development of similar scripts in different fields to guide medical learners on their learning journey.

Further dissemination of this resource could standardize oncology-specific education. As a field, oncology poses unique challenges to medical learners, as they learn to navigate complex medical histories and a myriad of emotions that are tied to a cancer diagnosis. Breaking bad news, comforting patients in vulnerable moments, and carrying conversations about death are skills of their own that take years to develop, and learning those skills alongside the skills of basic history-taking can prove overwhelming. We hope that our template empowers students with a tool to help develop rapport, advance patient care, and the opportunity to learn—balancing the oft-discussed tension between patient care and education.