Eleven 2nd-year medical residents were given the opportunity to take histories and give physical examinations for patients whose complaints included chest pain, palpitations, dyspnea on exertion, fainting, asymptomatic electrocardiographic abnormalities, and hypertension. Each resident took part in this program in an instructor's outpatient clinic twice a week for 2 consecutive months; each resident saw an average of 19 patients. The instructor discussed with the residents how to make diagnoses logically and the necessity of emergency treatment. The residents learned that taking histories accurately is an extremely important diagnostic tool, that a systematic approach is important, and that clinical decisions are often influenced by nonmedical factors. Medical residents need to have experience with such patients to improve their ability to take histories and perform physical examinations; however, proper supervision by an instructor in more important.

We have conducted weekly 40-minute training session of ECG diagnosis for lst-year postgraduate medical trainees for 6 months. Their abilities to read ECGs were tested before and after training sessions. Before training (just after graduation from medical school) they were able to diagnose typical ECGs if each tracing had only one abnormality and if enough time was given for interpretation. However, they frequently misdiagnosed even ECGs that they had correctly diagnosed on pre-tests if they were presented with many other ECGs and the time for interpretation was limited. Post-tests by students and teachers showed that our training of systematic and orderly reading of ECGs has enabled students to describe ECG findings fairly accurately but could not teach them to diagnose underlying cardiac disorders.

In the past 2 years, five 1st-year medical trainees with excellent knowledge and attitude trained with an instructor supervision in the physical examination of the heart with 4 to 5 patients a week. Despite their undergraduate medical education, these medical trainees could not detect abnormal physical findings of the heart. As much as 5 months of training was required before they could satisfactorily detect such abnormalities.

To improve the ability of 1st-year medical residents to take histories from patients with chest pain we had residents re-interview patients in a senior cardiologist's outpatient department who had had chest pain of known origin. Three medical residents participated in this training program just after obtaining their licenses to practice medicine. Each resident took histories from approximately 25 consecutive patients during a 1-month period. Causes of chest pain included angina pectoris (38 cases), acute myocardial infarction (16 cases), pulmonary embolism (10 cases), and dissecting aortic aneurysm (4 cases).
Each of the three residents stated that they recognized the importance of taking histories from patients with ischemic heart disease and became confident doing so after having interviewed about 15 patients. What they learned in this training program was considered useful when they interviewed new patients in an emergency room who complained of chest pain. One resident wished that this training had started several months after receiving his license because they had little experience taking histories from patients while in medical school. Four months after this training, the senior cardiologist tested the three residents by having them interview new patients with chest pain and found their abilities to be satisfactory.
Twenty consecutive cases appears to be a satisfactory number for medical residents to become confident in taking histories from patients with ischemic heart disease. This training program should be started within 3 months after residents receive their medical licenses.

With the development of sophisticated medical technologies, there has been a tendency to belittle the taking of the “history and physical, ” even in the field of cardiology. We have been holding cardiology case conferences for general medical residents, with the main focus on history taking and physical examination since 1992, so that all residents are able to provide a certain level of primary care for patients with cardiac diseases regardless of his or her future sub-speciality. We present our methods and the educational effect of these conferences.

Based on 20 years of experience with an unique postgraduate clinical training program, consisting of “g eneral wards ” and “inninr-residents in general medicine” at Tenri Hospital (Nara, Japan), we have identified the following points for the successful evaluation of residents: 1) unlike undergraduate teaching, item-based evaluations do not fit teaching in the clinical setting, 2) evaluation of residents' attitudes should be emphasized, 3) comprehensive evaluation in regular meetings by the teaching staff is practical and useful, 4) mechanisms to reflect patients' opinions should be included in the evaluation process.