Vestibular —
Training activity: 1

Details

Obtain a detailed diagnostic clinical history from complex vestibular cases with co-morbidities

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Empathic listening skills
• Patient-centred counselling skills
• Differential diagnosis approach
• Referral information
• Medical history
• Symptom duration, onset, chronology and sequalae
• Otological symptoms
• Neurological symptoms
• Effect on quality of life and employment

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • What constitutes obtaining a detailed history for complex vestibular cases, specifically those involving co-morbidities?
  • Have you discussed expectations for comprehensive history content with your training officer?
• What is your prior experience of this activity?
  • Have you previously taken detailed histories from complex vestibular patients or those with multiple co-morbidities?
  • What do you already know about history-taking techniques, including assessing physical, psychological, and functional impacts of vestibular conditions?
  • What specific challenges related to managing time, focusing the patient, or differentiating vestibular symptoms from those caused by co-morbidities might you face? How might you plan to handle them?
  • What is the scope of your own practice for history taking in complex cases? When will you need to seek advice or help, and from whom?
  • How do you feel about embarking on history taking in complex cases?
• What do you anticipate you will learn from the experience?
  • What specific questioning skills or techniques for managing information from complex cases do you want to develop or refine, drawing upon previous experiences?
  • What specific insights into the impact of vestibular conditions on patients and their significant others, or the unique challenges posed by specific co-morbidities, do you hope to gain?
• What additional considerations do you need to make?
  • Have you reviewed any actions identified from your previous reflections on obtaining complex patient histories?
  • Is there any important information you need to consider before starting, such as reviewing the structure for collecting information on psychological and functional aspects or clarifying red flags that necessitate immediate medical referral?

In action

• During the activity is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate during the history-taking for a complex vestibular case? Are you encountering situations such as:
    • A patient revealing significant, unanticipated non-audiological co-morbidities (e.g., neurological disorders, severe psychological issues, extensive complex medication) that complicate the diagnostic pathway?
    • A patient presenting with vague or conflicting descriptions of their symptoms, making it difficult to formulate a clear hypothesis or an individualised test strategy?
    • A significant other or carer providing conflicting information about the symptoms or timing of events?
  • How does this experience compare with previous experiences of similar history-taking activities?
• How are you reacting to the unexpected development?
  • How is the unexpected development being resolved as you progress during the activity? Are you successfully managing the situation yourself, or do you need support because the complexity requires immediate medical/neurological assessment beyond your current scope?
  • What are you learning in this moment as a result of the unexpected development? For example, are you learning a more effective way to structure the history to cover complex medication lists, or gaining proficiency in distinguishing vestibular symptoms from those caused by systemic co-morbidities?
  • How is this impacting your actions? E.g. Are you responding to the situation appropriately (e.g., focusing the history strictly on audiological/vestibular symptoms)? Are you adapting or changing your approach to questioning or listening?
  • Is this unexpected event affecting your ability to undertake the activity independently? Specifically, are you immediately recognising when the co-morbidity requires onward referral before continuing the assessment?
  • How are you feeling in this moment? For example, are you finding it difficult to adapt? Is it affecting your confidence in managing complex medical histories? Are you feeling positive you can reach a successful conclusion?
• What is the conclusion or outcome?
  • How are you working within your scope of practice? E.g. Are you successfully concluding the history taking, ensuring that the complexity of the case does not prevent the formulation of an individualised test strategy? Are you practising within your scope by immediately identifying co-morbidities that require onward referral (e.g., neurological evaluation) and focusing the history on audiological/vestibular symptoms?
  • What do you learn as a result of the unexpected development? E.g. Are you gaining proficiency in distinguishing vestibular symptoms from those caused by systemic or psychological co-morbidities? Are you learning a more effective way to structure the history to cover complex medication lists and previous non-audiological investigations?

On action

• What happened?
  • Begin by summarising the key points of the interaction, focusing on the patient’s presentation, complex aspects, and the core information you gathered.
  • Consider specific events, actions, or interactions that felt important, such as managing complexity or navigating information related to co-morbidities. How did you feel during this process?
  • Include any ‘reflect-in-action’ moments, where you had to adapt your questioning or approach as the complex history unfolded.
• How has this experience contributed to your developing practice in history-taking?
  • What learning can you take from this complex case experience?
  • What strengths did you demonstrate in obtaining the history? What skills or knowledge gaps were evident, particularly regarding complex cases or co-morbidities?
  • How did this experience compare to previous history-taking attempts? Were any previous actions for development achieved? Has your practice improved?
  • Identify any challenges you experienced (e.g., managing information flow, patient communication, time constraints) and how you reacted to these. Did these challenges affect your ability to deal with the situation? Were you able to overcome them?
• What will you take from this experience moving forward?
  • Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you received.
  • What will you do differently next time you take a history from a complex vestibular case?
  • Has anything changed in terms of what you would do if you were faced with a similar situation again?
  • Do you need to practise any aspect of obtaining a detailed clinical history further? E.g.
    • Do you need to research the impact of specific neurological and psychological co-morbidities on vestibular presentation to better inform history- taking and test strategy?
    • Do you need to practise specific questioning techniques aimed at efficiently extracting functional and psychosocial information from complex patients within time constraints?
    • Do you need to more clearly document the rationale for adapting the assessment strategy based on the patient’s complex history or physical limitations?
    • Do you need to better understand when to seek supervision on managing the flow of information when patients present with chronic, multi-layered symptoms?

Beyond action

• Have you revisited the experiences?
  • Have you revisited your previous reflections (reflect-before-action, reflect-in-action, and reflect-on-action) for this specific activity (obtaining a detailed clinical history from complex vestibular cases)?
  • When reviewing these past reflections, what actions for improvement did you previously identify you would need to take to improve your practice related to eliciting information about specific co-morbidities, structuring the history efficiently, or managing complex patient narratives?
  • Have you completed these previously identified actions? If not, what are the barriers? If so, how did completing them impact your subsequent performance of this activity? Are you ready to demonstrate this new learning confidently and consistently when performing this task?
  • Have you engaged in professional storytelling or discussed your experiences of complex history taking with peers, near peers, or colleagues? Has discussing these experiences with others changed your view or understanding of the diagnostic value of specific history components or the necessity of considering physical, psychological, and functional aspects?
•  How have these experiences impacted upon current practice?
  • Considering your cumulative experiences and reflections on this activity, how will the learning you have gained support you in preparing for relevant observed ‘in-person’ assessments for the module?
  • How has your practice related to obtaining a detailed diagnostic clinical history developed and evolved over time across multiple instances of undertaking this ETA? Can you identify specific examples of improvement or increased confidence in managing complexity, identifying subtle red flags, or forming an initial hypothesis?
  • Based on your experiences, how has your ability to recognise when something related to complex vestibular history taking is beyond your scope of practice improved? Do you have a clearer understanding of when and from whom (e.g., supervisor, neurologist, ENT specialist) you need to seek advice or clarification regarding unusual symptom clusters, highly complex co-morbidities, or suspected central pathology?

Relevant learning outcomes

#	Outcome
# 1	Outcome Collect a detailed patient history which informs an individualised test strategy and rehabilitation plan.