Bedside Teaching (BST)
Posted by Afandi on December 20, 2008
* Analyze your current perceptions on the use of bedside teaching as an instructional tool for residents and students.
* Recognize and list the benefits of bedside teaching for learners.
* Recognize and list the benefits of bedside teaching for patients.
* Describe strategies to effectively deal with the following hurdles to the implementation of bedside teaching:
* time constraints
* group accommodation
* case presentation
* learning climate for both teacher and learners
* hospital and patient barriers
* Plan to incorporate bedside teaching into your instructional methods during the upcoming months.
Bedside Teaching Pearls
1. Establish rules of conduct for bedside presentation early in the rotation.
* Residents should not whisper in the patient’s room
* Calls should be made discreetly outside the room
* Laughing at a patient and the patient’s responses is never appropriate
* Describing the patient’s sex and race in front of the patient is awkward.
* Behavior should be proper and respectful – never flippant.
What are your own personal rules of conduct or expectations?
2. Make appropriate introductions between the patient and the learners.
3. Insure that the setting of the room is suitable for learning.
* Pull the patient’s bedside curtain
* Shut the patient’s door for privacy
* Invite family members and friends to wait in the lobby
* Ask the patient for permission to shut off the television
4. Demonstrate appropriate communication techniques and allow the patient the opportunity to clarify the case presentation.
Sometimes residents and students are frustrated to hear different details told to
the attending physician than what was told to them only an hour before! This apparent conflict can be an excellent learning opportunity.
5. Teach in the presence of the patient.
This gives the patient the opportunity to learn about his/her disease and the patient receives confirmation that the team is actually considering every aspect of the case. It may also prompt new information from the patient.
6. Be careful about asking the student or resident who is caring for the patient a question that they are unable to answer.
Although the “Socratic method” is helpful in stimulating thinking, this can lead to undermining the patient’s confidence in the team’s knowledge.
7. Avoid shoptalk.
Using medical jargon without including the patient in the discussion can lead to apprehension in the patient. The team should discuss medical points or parts of the lab and EKG with the patient and explain their significance with language that is “education-level appropriate.”
Watch for terms that may be culturally inappropriate or frightening to the patient. Especially when considering all potential differential diagnoses. Patients may react to terms such as “cancer.”
8. Find out from the team what portions of the physical exam give them difficulty, then discuss and demonstrate proper techniques.
During the demonstration of the physical exam it is imperative that patients are appropriately draped and that the patient’s dignity is protected.
An additional value of bedside teaching rounds is that the history, the physical, the assessment and the plan can all be reviewed at the bedside in the presence of the patient so that appropriate Medicare documentation may be made later.
9. As the bedside presentation closes . . .
* Leave the patient with an overview of his/her disease process.
* Always give the patient an opportunity to ask remaining questions
* Make and discuss plans in the patient’s presence and with their input
What the Literature Says
Bedside teaching is “the way things used to be,” the old way, the “when I was in medical school” way of educating medical learners. It is the tradition which medical educators from the middle part of this century would shudder to find waning today. At the bedside, generations of students have observed science meet the art of medicine, have been indoctrinated in the demeanor and approach of a physician as he/she examines a patient, and have been challenged to be prepared and observant.
However, while rounding with residents at the bedside and leading workshops for attendings on bedside teaching, certain comments invariably arise:
* “I think bedside teaching rounds make patients feels exposed and uncomfortable.”
* “I had an attending once who wanted to do bedside teaching rounds; they were a horrible example of how physicians should teach patients. I determined at that time I would never do bedside teaching rounds.”
* “Bedside teaching rounds are inefficient and take too much time.”
What does the literature say?
Educators have studied physician and patient views on bedside teaching, and have also looked at outcome measures. Kurt Kroenke, et al1. surveyed physicians involved with teaching in order to find out their attitudes toward attending rounds.
* Ninety-six percent of residents and 88% of attendings preferred that cases NOT be presented at the patient’s bedside.
* Respondents believed that only 30% of an attending’s rounding time should be spent at the bedside.
A study at the Medical College of Wisconsin2 demonstrated that only 2% of housestaff and 4% of students felt comfortable presenting cases at the bedside.
* Forty-seven percent of attending physicians who had practiced medicine less than 10 years favored presenting and teaching away from the bedside.
* However, 85% of patients preferred to be present when their cases were presented.
* An indication that this move away from the bedside has been a relatively recent phenomenon is demonstrated by the fact that only 18% of those attending physicians in practice 10 years or longer preferred presentations and teaching away from the bedside.
Survey studies such as these prompted a more vigorous controlled clinical trial by Lehmann and Brancati at Johns Hopkins in 19973. They randomized resident attending teams to make case presentations during morning rounds either at the patient’s bedside or in a conference room for one week. They used a patient perception questionnaire that was administered within 24 hours in order to determine the patient’s perceived quality of care.
There was no significant statistical difference in the patient’s perceptions of whether
* Their problems were explained adequately
* Tests and drugs were explained adequately
* Patients were treated with respect
* The rounds caused them worry
* The quality of their care suffered
Nair4 asked a group of 100 patients about their impressions of bedside teaching after they had had their case presented and discussed at the bedside.
* Sixty-eight percent found that it increased their understanding of their medical problems, 77% said they enjoyed it (only 17% did not), 83% said it did not make them anxious, 85% said they do not think that bedside teaching breaches confidentiality, and 84% said they would recommend bedside teaching to other patients.
* In this same study, 100% of the students, interns and residents (N=136) believed bedside teaching was valuable and, once they experienced it, over half said they did not receive enough of it.
So, in the literature we see that physicians have echoed some of our same initial reactions to bedside teaching. And yet, when bedside teaching is actually studied, patients and learners appreciate it and find it effective . It is time we stopped blaming patients and students for our own insecurities at the bedside.
1 Kroenke, K. Attending Rounds: A Survey of Physicians Attitudes. JGIM Int Med. 1990; 5:229-233.
2 Wang-Cheng, et al. Bedside Case Presentations: Why Patients Like Them But Learners Don’t. JGIM Int Med 1989; 4:284-287.
3 Lehmann LS, Brancati FL. The Effect of Bedside Case Presentations on Patients Perceptions of their Medical Care. N Engl J Med 1997; 336 (16): 1150-1155.
4 Nair BR. Student and Patient Perspectives on Bedside Teaching. Medical Education 1997; 31:341-346.
Getting Started with Bedside Teaching
Read these two excellent articles on-line by using the hyperlinks from this page.
LaComb MA. On Bedside Teaching. Ann Int Med 1997; 126(3):217-220
Kroenke K, Omori DM et al. Bedside Teaching. Southern Medical Journal 1997; 90(11):1069-1074.
Evaluation of the Module
After completing this module…
I have analyzed my perceptions on the use of bedside teaching as an instructional tool for residents and students. Strongly Agree
I can recognize and list the benefits of bedside teaching for learners. Strongly Agree
I can describe strategies to effectively deal with various hurdles to the implementation of bedside teaching. Strongly Agree
I can recognize and list benefits of bedside teaching for patients. Strongly Agree
I plan to incorporate beside teaching into my instructional methods during the upcoming methods. Strongly Agree
This information will be useful in my teaching. Strongly Agree
Post Test – Bedside Teaching
1. Preceptors observe learners in the clinical setting only to assess technical skills.
2. To allow an unbiased observation of the learner’s clinical skills, preceptors must not participate in a learner-patient encounter.
3. Preceptors should change their purpose for observing learners in the clinical setting the course of a clerkship/rotation.
4. Preceptors should assign office staff to act as observers for learners and provide feedback to them.
5. Preceptor feedback often provokes learners with anxiety and is not valued as an effective teaching method.
6. If a learner is doing well, preceptors do not have to provide feedback to be effective.
7. Preceptors should avoid feedback that tells learners what they ought to do and how they ought to do it.
8. Preceptors should provide personal judgments on learner performance when giving effective feedback.
9. Preceptors should provide immediate feedback to learners to enhance learning.
10. Feedback and evaluation generally refer to the same process in the clinical learning environment.