Strategies for Teaching in a Busy Practice

Strategies for Teaching in a Busy Practice

What are the teaching strategies, techniques, or methods you could use during patient care situations (e.g being “shadowed” by a student)?

Most daily teaching uses a combination of six general strategies:

* Precepting using the “microskills”
* Being observed/shadowed by student
* Observing students
* Giving “mini-lectures”
* Mentoring student projects
* Learning with students (looking things up or working things out together)

No single strategy is ideal – each has advantages and drawbacks. The optimal teaching strategy depends on the interaction of the student, the teacher, and the situation. In practice the choice of strategy is made so quickly that it is almost instinctive. There is seldom time to ruminate on the optimal teaching technique for a given situation!

Depending on your natural learning and teaching styles, certain teaching strategies are more comfortable and hence used more frequently than others in your practice. Using a mixture of methods makes teaching more enjoyable and is probably more effective. Each strategy can be learned and practiced.

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Most teaching skills are similar or identical to skills required for patient care

You can draw on both positive and negative experiences in your own education

As residents and students are adult learners, the role is more similar to coaching than traditional classroom teaching.

Busy clinicians are usually proficient in at least four of the six strategies listed above. As you go through the modules, you will probably recognize things you already do in teaching. Our aims are to validate many of your current teaching practices and to provide new information you can incorporate into teaching. By combining medical education theory with practical experience, we hope to enhance your confidence as an educator and contribute to teaching being an enjoyable and worthwhile part of your practice.

“Precepting must be highly efficient because both the learner and preceptor are responding to many time demands” (Neber JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills” model of clinical teaching. JABFP 1992; 4:419-24.)
Bedside Teaching
Learning Objectives

* 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
* selectivity
* demonstration
* observation
* 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.

For example:

* 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.

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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.

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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.
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.

On Bedside Teaching

Michael A. LaCombe, MD

1 February 1997 | Volume 126 Issue 3 | Pages 217-220

Actual teaching at the bedside during attending rounds, with emphasis on history taking and physical diagnosis, has declined from an incidence of 75% in the 1960s to an incidence of less than 16% today. Profound advances in technology, in imaging, and in laboratory testing and our fascination for these aspects of patient care, account for part of this decline, but faculty must also assume responsibility for the present lack of bedside teaching. If we are to reverse this trend, we will need to realize the barriers to bedside teaching, both real and imagined, and overcome them. And if we are to become effective bedside teachers, as were our mentors, we will need to sharpen our own physical diagnostic skills. We will need to learn how to be gentle with students and housestaff, how to better communicate with patients, and how to teach ethics and professionalism with the patient at hand.

Some time ago, when visiting a great university medical center in the northeastern United States, I asked the faculty whether the teaching of clinical medicine at their institution was done at the bedside.

The umbrage was palpable.

All of their teaching was at the bedside, I was informed. They taught in the British tradition. Wouldn’t have it any other way, they nodded in unison. And so on.

The following morning I was led by the chief resident through a labyrinth of buildings and corridors to a conference room full of students and housestaff. The chief resident politely introduced the nervous young student who was to present “the case” that morning. She in turn promptly began to recite the patient’s history.

“Could we go to the bedside?” I asked.

“Of course,” said the chief resident, leading the group out into the corridor. There we stopped, and the student, dodging carts conveying breakfasts and pharmaceuticals, once again began her presentation. I interrupted a second time.

“I meant, the actual bedside….”

“Oh, sure,” said the chief resident, and promptly led us down long corridors to the patient’s room. They stopped at the door for what might have been a “door-jamb presentation” had I not continued on into the room, introduced myself to the patient and his family, and motioned for the students to join me.

It seemed to be an utterly foreign experience for them. If I could not read their minds, I could certainly read the concerns in their faces. The family would be asked to leave, wouldn’t they? We certainly wouldn’t discuss the patient’s social history in front of him, would we? Will he embarrass me in front of all these people?

We circled the bedside. There were 17 of us all together, as I remember. The student-presenter stood just opposite me on the other side of the bed. I motioned for her to continue. Flustered, she pulled out a stack of index cards and began to read. Gently I reached across the bed, took the cards from her, and said,

“You really don’t need these. Tell me what you remember, just from memory.” I caught her eyes with mine, smiled, and nodded. I could see her relax a bit. She began.

Ninety minutes later we finished with our teaching session. There had been the Terry nails, the spider angiomata, the conjunctival icterus. The students had spotted those right away, gotten them easily. The deep booming ventricular gallop, in a cadence you could set your watch to, came a bit tougher. But no one seemed to bluff. Each listened until that sound was fixed correctly. They were having fun by that time, no longer threatened. They pored over the hyperpigmented palmar creases, accented like major highways coursing across a road map, showing the way. Someone volunteered to check for asterixis, another for fetor hepaticus, and a third gave us some biochemistry. A fourth confidently reviewed the genetics of hemochromatosis.

In the end, there were diagrams and pathways drawn on the undersides of Kleenex boxes, on the palms of several hands, and even, we’ll confess, on the bed sheets. The patient was beaming, his family effusive in their gratitude. The students didn’t want to leave.

Out in the corridor, as we headed toward the next “case,” the chief resident turned to me and shyly asked, “Sir, is that the way they did it in the old days?”

Well, yes, it was.

In the old days, 30 years ago, 75% of teaching was at the bedside [1]. That was just the way we did it. By 1978, that figure had decreased to 16% [2]. By all estimates, it is even lower today.

Now at this point, everyone will hasten to add that although that may be true nationwide, at their institution, bedside teaching is the rule. But when you actually look for it, when you ask the housestaff, who are still delightfully ingenuous, you find that most “bedside” teaching is merely “corridor” teaching, or “door-jamb” teaching, or even simply patient-centered teaching in a conference room.

Why is this so?

Well, we could blame the housestaff. That’s easy. And they are in some measure culpable. They are fascinated with technology these days, want to review the imaging and laboratory analyses, want to have fed to them long lists of differential diagnoses meticulously drawn on the blackboard. They are used to the doughnuts and coffee, the comfort of sitting around a conference table, the cloak of early morning semiconsciousness.

But much of the blame rests with us. For faculty, the lecture form of teaching is what we know best, and, in many cases, all we know. And besides, in the safety of the conference room, we can be in control.

There we may shift the focus, guide the discussion, and channel the thinking into our own special areas of expertise. There will be no patient and no family in attendance to ask the embarrassing question that forces us to say, “I don’t know.”

As well, there is the professor’s fear of the unknown, of medical problems outside one’s own subspecialty, of an inability to discuss ad infinitum an obscure disease entity that one has not been able to read about the night before. And there is the faculty’s discomfiture with physical diagnosis.

We create imagined barriers to bedside teaching: that to discuss the social history in front of patient and family is an invasion of privacy and that the family’s presence is itself an impediment to bedside teaching. But how can a patient, who has given us the social history, be embarrassed by it if sensitive issues are handled with discretion? And, in these days, when families are convinced that physicians no longer care for patients, would a family really object to their loved one becoming a focus for teaching? There is the ready excuse that testing and imaging necessarily absent the patient from a session of bedside teaching. That is easily overcome. Have the housestaff make certain beforehand that off-ward testing will not conflict with your bedside rounds. Enlist the aid of the nursing service that will ensure the availability of your patients, especially if you are thoughtful enough to invite nurses to attend your rounds with you. Finally, inform the patients that you will be coming by at the appointed hour.

Patients, who enjoy this sort of attention immensely, will be perfectly certain they are available when you come on rounds.

Acquired skills in history taking and in physical diagnosis are the obvious benefits of bedside teaching. Clinical ethics can best be taught there [3]. But there are other, less apparent fruits of this endeavor. At the bedside, one is discouraged from using medical jargon. And in this era in which housestaff too often refer to patients as “dirt balls, train wrecks, last night’s hits, and gomers,” as though such phrases were elevated prose, pejoratives are discouraged. Housestaff learn not to sit during this patient encounter, that this is bad manners, and that, most important of all, one never sits on the patient’s bed, certainly, at least, without permission. One does not call the patient by his or her first name. One begins to learn respect for the patient. At the bedside, the housestaff begin to see disease as an illness happening to a human being. In other words, one learns to be professional. And one learns communication.

Perhaps most important of all, bedside teaching begins to foster another wonderful link with the past. The housestaff watch you as carefully as does a child his parent, watch you attend to the patient, watch you observe; they catch your powers of diagnosis, the respect you hold for this other human being; they feel your attitude, your caring. The students witness your own dignity, and the love you have for medicine, and for teaching them. They link with you, and bond. And mentoring begins.

Such teaching encounters can be great fun. Not long ago, the housestaff presented me with an “unknown rheumatic heart.” Wanting to show the students how I might proceed to a diagnosis and still have fun with them at the same time, I told them I would examine the patient only through observation and with my hands. (My courage came from noting that the young woman had a pronounced malar flush, cold fingers and hands, and a rather evident right ventricular lift, visible even through her hospital gown.) I had them feel the lift and the pronounced pulmonic closure, reached for my stethoscope while pointing to the patient’s second left interspace, told my students that I would bet if we listened there, we’d hear a loud, snapping S-2-P, and maybe even a Graham Steell murmur. But without listening, I repocketed my stethoscope and went on palpating. Finding the diastolic apical thrill (and much relieved by the discovery), I reminded them of the purring of cats, had each of them lay a hand at the apex, and made certain each of them appreciated the finding.

“I’ll bet there’s a great mitral rumble right there,” I said, reaching for my stethoscope once again, then declining to listen for a second time. And although I couldn’t feel the opening snap, I pointed to where it might be, teasing the students with my stethoscope a third time. At this point, the young lady next to me could no longer contain herself. Grabbing her stethoscope, she slapped its diaphragm on the patient’s cardiac apex, looking up at me apologetically.

“I just couldn’t wait any longer,” she explained.

How do patients react to teaching at the bedside? They love it. They love the attention, revel in the bedside repartee, and feel finally that physicians are interested in them and are communicating with them. Finally, they are able to ask questions of physicians who do not seem rushed to leave. At bedside, the patient learns the chief secondary purpose of your institution, that of teaching students. They, the patients, become participants in this and no longer feel like laboratory animals caged for student experimentation. Their fears are addressed, their anxieties are allayed, they learn more about their illnesses, and, if you subscribe to psychoneuroimmunology, healing begins.

Bedside teaching is about as intuitively obvious as is any other kind of teaching. Which means that it is deceptively difficult, perhaps the most difficult sort of teaching of all. You want your students to learn, after all, and they will not learn if they are full of fear and trepidation, anxiously squirming and biting their lips, causing their pagers to go off, wanting to escape, wishing to avoid the torture of the adversarial goading that too often substitutes for bedside teaching. No one can learn under these circumstances. And the faculty member who so conducts rounds will find rapidly dwindling numbers of students at the bedside.

There is homework to do for this bedside teaching endeavor, and there are rules to follow. The bedside teacher had better be proficient in history taking and be a quintessential physical diagnostician. You have to learn these skills all over again. Or for the first time. And you have to work at it. Begin with Schneiderman’s excellent annotated bibliography on physical examination and interviewing [4]. Review the recent work on the teaching of physical diagnosis and note particularly that didactic sessions without a patient as the focus do not seem to work well [5,6]. Have your housestaff organize weekly “physical diagnosis rounds” and attend the rounds with them. Convince yourself of the utility and accuracy of bedside diagnosis [7-12]. Consult the best texts on the subject [13-20]. Use your echo laboratory as a great resource for finding patients with intriguing murmurs. Finally, broaden your horizons-“bedside” does not imply only an in-patient hospital setting. The outpatient clinic and the nursing home are great places to conduct bedside teaching [21,22].

The bedside teacher needs firm grounding in basic science, although not exhaustively so. These days, that means molecular biology, among other things. Learn some. Learn at least enough to know which questions to ask. Your housestaff will teach you the rest. Don’t be embarrassed by their teaching. You will find after all that learning does go both ways.

And if you are visiting another program and plan to teach at the bedside and there is a single case of hemochromatosis, or bacterial endocarditis, or Wegener granulomatosis anywhere in that institution, rest assured that you will see it. Be prepared.

Prepare your new housestaff team as well. Before you go in to see your first patient with them at the bedside, set some ground rules. Inform the housestaff that any theoretical discussion of differential diagnosis, diagnostic testing, and pathophysiology carried on at the bedside must always be prefaced by an understanding with the patient at hand that such discussions are for teaching only and do not necessarily pertain to the patient’s situation and that the patient is free to interrupt the discussion and ask questions at any time. Any discussions potentially frightening to the patient and any sensitive issues can be discussed later.

When entering the patient’s room with your housestaff team, always introduce yourself to the patient and, after that, introduce your group at large, emphasize that this is a teaching encounter and not a diagnostic or therapeutic one, repeating to the patient that there will be clinical entities and diagnoses mentioned that have nothing whatsoever to do with this particular patient. Reassure the patient that if, despite all explanation, the patient still harbors fears or doubts, the patient is encouraged to express these to the group, and those questions will be answered.

If there are family in the room, ask first the patient and then the family if they wish to stay. There is seldom any reason on teaching rounds to remove family members from the scene. Have the housestaff explain complicated issues to the family and answer questions. It is a part of the teaching of communication. The patient may address most or all questions to you-you are the professor, after all. But you are there to teach rather than to seize control. Refer all questions to the students. Have them come up with the answers. Make gentle corrections where necessary.

Avoid asking the housestaff impossible questions. Don’t ask “What am I thinking?” questions. Avoid asking questions designed merely to display your own intelligence. And as soon as you do, admit your error, apologize for it, and answer the question yourself. Inform your housestaff of the changing nature of the patient’s history, that what is revealed today may not always correlate with what has previously been recorded, that such is the norm and no one should be shamed because of it. Remind them that one purpose of bedside teaching is communication: affording the patient an opportunity to expand on the history, allowing him or her to validate its accuracy and to ask questions of the housestaff and attending physicians. Emphasize this ground rule with your housestaff: Unless everyone, patient included, feels better after the bedside rounds, those rounds were not successful.

Perhaps most important of all, reassure your students that you will try not to embarrass the patient’s physician. Indeed, tell them you will try not to embarrass anyone. Because the patient’s physician is usually the student presenting the case, make it abundantly clear that whoever is presenting the case will not be asked any questions of a theoretical nature. Nothing makes the patient or student more uncomfortable than to display that student-physician’s ignorance. Reassure your students that that is not your game. And in that connection, tolerate no jousting of other physicians.

Don’t ask a question of a junior member after a senior has already missed the question. Remember, try not to embarrass anyone. You do not want these rounds to degenerate into a shark-feeding frenzy. Students can be adept at this if encouraged. They are competitive. They have already had a good deal of training in one-upmanship and in how-to-lacerate-your-neighbor. Discourage this, if you want bedside teaching to be fun, and if you want learning to take place. Control voluntary one-upmanship as well. If the chief resident hesitates over the differential diagnosis of a malar rash, never let a medical student blurt out the answer. One may argue that this too is learning from one another. But it is also “blood in the water.” The sharks will soon circle, and your teaching rounds can degenerate. You do not want this.

Teach professionalism. Gently. Make the students proud of themselves, have them respect each other, and teach them to respect the patient. They will not chew gum. They will not attend with a cup of coffee in hand. There will be no leaning against the wall, no sitting on the edge of the bedside table. Discourage their wearing last night’s pajamas in front of a sick human being. Teach them to be professionals. And while you’re at it, teach them to teach each other.

Teach observation. Osler did. Albright did. Morgan and Engel did. You do it. When the presentation of history is completed and before the physical examination is recited, call on someone to point out three physical findings. While your student searches for the rash, the ptosis, and the surgical scar, watch the eyes of the other students. They will have suddenly come alive, have realized that observation is important and that their turn will come. Turn them all to the window, then have them recite the contents of the bedside stand, or describe the patient, or the patient’s room. Have them “deconstruct.” That is, have them tell you what is not there, and what they might learn from that.

Learn when to say “I don’t know,” learn when to play the dumb farmer and when to play the Socratic gadfly. It will allow your students to teach, to learn, and to discover for themselves, rather than merely to be lectured to.

And when you have done all of this, you will find that you have made your bedside rounds fun rather than adversarial, that it is possible after all to get a whole conference room of students, all 23 of you, around the bedside. You will learn that your students have a great deal to teach you, and that patients do as well. You will become filled with tradition, infected with a legacy. And you will find yourself hurrying off to work in the morning, rushing to get to the bedside.

Requests for Reprints: Michael A. LaCombe, MD, 103 South High Street, Building A, Bridgton, ME 04009.

Bedside Teaching

KURT KROENKE, MD, Bethesda, Md; DEBORAH M. OMORI, MD, MPH, Washington, DC; FRANK J. LANDRY, MD, MPH, Burlington, Vt; and CATHERINE R. LUCEY, MD, Washington, DC

Abstract

Background. Clinical teachers have been exhorted to “return to the bedside” so that the three critical partiesóteacher, trainee, and patient-can participate together in the educational encounter. The presence of the patient is deemed essential for the optimal demonstration and observation of physical examination, medical interviewing, and interpersonal skills, as well as role-modeling professional and humanistic behavior.

Methods. This essay reviews the challenges inherent in bedside teaching and proposes strategies to enhance both the effectiveness and efficiency of such teaching.

Results. Practical suggestions are provided regarding teaching issues (time constraints, group accommodation, selectivity, demonstration, observation, case presentations), learning climate for both teacher and learners, hospital and patient barriers, and selected other issues.

Conclusions. Despite changes in the clinical setting and financing of medical education, patient-centered teaching will remain essential to the training of future clinicians. Techniques described in this paper can be useful in facilitating such bedside teaching.

THE PATIENTÍS BEDSIDE is the ideal setting for teaching physical examination, medical interviewing, and interpersonal skills. While ìdemonstrating physical findingsî is the most commonly reported objective for bedside visits, difficult parts of the interview can also be demonstrated or observed, such as asking about alcohol use; inquiring about depression; handling emotions such as anger, fear, or grief; and educating, motivating, counselling, and supporting the patient. In so doing, professionalism and humanism can be role-modeled. Patient contact itself is a laudatory goal of bedside visitations that allows for precious minutes between doctors and patients, since patients may not see or talk with their physicians during most of the day.

Research on bedside teaching is rather sparse. The handful of original investigations have either focused on a single issue, such as case presentations1-3 or competency in physical examination,3-7 or have examined only a few broad aspects of bedside teaching in more general studies of clinical teaching.8-15 Several educators have written helpful essays on bedside teaching.16-23 Our aims in this paper are to highlight the unique challenges and difficulties inherent in bedside teaching and to offer practical instructional strategies.

What will not be addressed are several new financial considerations that have impact on bedside teaching, particularly in the United States. First, new regulations of the Health Care Financing Administration require attending physicians to be “present” during significant portions of the evaluation. Second, because of declining subsidies for medical education, attending physicians are increasingly pressured to generate clinical revenues. In a sense, these considerations compete, with the first factor potentially leading to more time at the bedside (although not necessarily in a teaching mode), and the second factor compelling the attending physician to shorten the time devoted to bedside teaching. In either event, our experience in dealing with these constraints is limited, and speculating on solutions (discussed briefly by Ende23 elsewhere) is beyond the scope of this essay. Instead, we focus on teaching issues, learning climate, patient and hospital factors, and several other issues that relate more to the quality than to the quantity of time alloted to bedside teaching, although in doing so we will provide some suggestions for making such teaching efficient as well as effective.

TEACHING ISSUES

Time Constraints

What percentage of time on teaching rounds should be spent at the bedside? Surveys of what is actually done or what teachers and learners think is appropriate give estimates of 15% to 30% of time together as a team.8,12,14 However, there is little information on whether the amount of time spent at the bedside affects either educational or patient care outcomes. Also, should one look at a ìpie chartî of time allocation for a single session of rounds, or for an entire rotation? In the first case, an attending physician may aim to spend a certain portion of every session of rounds (eg, 30 minutes) going to the bedside, whereas in the ì1-monthî view, the attending physician may spend most of one session of rounds seeing patients, and much of the next session in the conference room. The time required to see patients with the entire team also depends on how much time the attending physician can devote to ìhomework,î ie, seeing patients outside of teaching rounds, either on his own time or as a passive observer during selected sessions of work rounds.21 Time spent at the bedside may also depend on the number of patients, the proportion that are new admissions, and patient complexity. Ironically, however, as patient load and acuity increase, so too does resident work load. In such cases, particularly when learners have been on call and are sleep-deprived, the attending physician may actually want to shorten rather than lengthen formal rounds, completing some of the bedside visits “solo,” and go over teaching issues with the team later.

Group Accommodation

First, the sheer number of learners can be intimidating and demands considerable ingenuity on the part of the attending physician. How does one physically crowd four to eight team members around a patientís bed so that everyone has an unobstructed view? Also, how does one keep multiple learners involved and interested, so that ward rounds are not, as one teacher quipped, a “mass of shifting dullness”? Another issue is the different levels of learners (or ìheterogeneityî): the formidable task of meeting the learning expectations of medical students, interns, and residents.

Selectivity

Making choices and maintaining focus is one strategy for effective bedside teaching with a large, diverse group. The ideal on teaching rounds (in distinction to work rounds) is to see a limited number of patients, visiting those who are expected to be of greatest teaching value. Even with these selected patients, the team should decide on the goal(s) of the visit: to demonstrate something on physical examination? to determine whether the patient is depressed? to comfort, counsel, or answer questions of the patient or family? Certainly, there can and will be courtesy visitsóthe attending physician is introduced, asks how the patient is feeling, and promises to return for a longer visit. However, some of these visits-especially when the number of patients is large-can be conducted by the attending physician outside of group time. Everyone is busy on the wards, with many tasks, so remember that group time is expensive. Some attending physicians go so far as appointing one team member as the “time keeper.”

While certain physical findings (skin lesions, joint findings, tremor) can be shown quickly to a large group, other parts of the physical examination, such as the cardiac or neurologic examination, are more time intensive. In such cases, the attending physician may need to “compromise” the optimal technique (in which each learner listens to a patientís heart as an “unknown,” putting the patient through all the positions and maneuvers) and instead focus the examination: ìListen over the apex with the bell of your stethoscope and describe the murmur you hear in diastole.î Learners then can come back on their own for a fuller examination.

Deciding which patients to see can be done in several ways: (1) The attending physician can listen for clues during the presentation (“poor historian”; inconsistencies or confusing aspects of the history; abnormal findings on examination). (2) The team can be asked at the beginning of rounds which patients they want to visit together, thus making the choice of patients, at least in part, learner-centered. (3) The attending physician may discover on chart review or in seeing patients on his own some valuable reasons to take the team to the bedside.

Demonstration vs Observation

In some cases, the attending physician demonstrates interview and examination techniques, verifying or augmenting what the learners have presented. In other cases, the attending physician can have a team member ask selected questions of the patient (clarifying whether the chest pain is angina or the fatigue is a symptom of depression) or perform a certain aspect of the examination (palpate the spleen; listen for an aortic regurgitation murmur; determine whether there is a joint effusion). Demonstration is quicker; observation takes longer, but keeps team members active, and allows the attending physician to observe skills and provide feedback. The attending physician can even assign multiple roles: one learner interviews or examines; another observes technique; another monitors the patient for reactions.

Another educational “game” is round robin: various learners can spontaneously suggest findings they might expect to see (eg, in a patient with cirrhosis, findings might include spider telangiectasia, temporal wasting, palmar erythema, gynecomastia). The attending physician can then ask learners to demonstrate their findings. The same can be done with the interview, charging the team members to think of questions they might like to ask the patient to clarify or confirm their differential diagnosis.

Case Presentations

These may occur at one of three sites: conference room (sitting), corridor (standing), or bedside (in patientís presence). Studies actually show patients like bedside presentations, but learners may be uncomfortable.1-3,18 Attending physicians may want to discuss this with the team and experiment with various sites. Bedside presentations allow the patient to clarify or amend data. However, the team must be cautious of technical jargon, as well as personal or sensitive issues.

Alternative Strategies

Accompanying the team on an occasional session of work rounds allows the attending physician to observe the team-patient interactions and bedside skills. However, if work rounds is the residentís bailiwick (as it is in many teaching programs), it is important for the attending physician to explain in advance why he is tagging alongónot to usurp the residentís leadership role but to assume more the role of a silent “UN observer.” Separate student rounds may be used occasionally to go over more elementary bedside findings. Occasionally, a patient can be invited to morning report to allow other teams to interview or examine the patient. Also, one can sometimes visit other teams’ patients, particularly when there is a classic finding (as long as the patient and the other team give permission).

LEARNING CLIMATE

Perhaps in no other educational setting is learning climate as significant an issue as it is during bedside teaching sessions. Interestingly, learning climate issues exist for attending physicians as well as students and residents. Fear of appearing ignorant or unprofessional in front of a patient is one of the concerns most physicians have about presenting in front of and examining patients during bedside teaching rounds.1

Many younger clinical teachers may have had inadequate exposure to bedside teaching during their own training. Concerns about the quality of their own physical examination skills (or particular aspects such as the cardiac, rheumatologic, or neurologic examination) may contribute to attending physiciansí fear of bedside ineffectiveness. This may be particularly true for educators who, by virtue of job description or reliance on technology, do not perform many physical examinations themselves. Compounding performance anxiety is the misperception that bedside teaching must focus on unusual and rare findings.

Several recommendations can be made to enhance the attending physicianís level of comfort at the bedside. First, recognize that there is probably no physical finding too mundane to review with a group of learners. It is the rare student or resident who has mastered basic examination techniques and interpretation. Simple cutaneous findings such as cherry angiomas, senile purpura, and seborrheic keratoses are as important to recognize and understand as is the more unusual necrobiosis lipidica diabeticorum. Second, the fact that a finding is chronic does not negate its teaching value. Pointing out the presence of frontal lobe signs in a patient with advanced dementia or delineating why one believes a murmur is a flow rather than a pathologic murmur may expose the residents to findings that they have not attempted to elicit or interpret on their own. Third, if there is a particular examination technique or physical finding that the attending physician cannot recall, ask if any learners in the group can demonstrate and, if no one knows, learn together as a team, through reading or consultation. Finally, role-modeling professionalism and compassion for hospitalized patients or for outpatients with health concerns can be extremely valuable and is generally a skill that seasoned attending physicians have perfected through experience with multiple patient encounters.

Learners may dislike bedside rounds for several reasons. Impatience or boredom can arise when rounds are poorly planned or when one individual spends a large amount of time examining the patient while the rest of the team stands and watches. A second reason is the fear of being embarrassed in front of the patient by unexpected findings or by questions for which they do not have an answer. The attending physician may want to shift from a classroom style of teaching involving open-ended questions (eg, “listen to the heart and tell us what you find”) to more directed demonstration (eg, “listen with the diaphragm of your stethoscope at the upper sternal border where you can hear a blowing diastolic murmur consistent with aortic insufficiency”). This technique may not allow evaluation of the learnerís innate skills in eliciting a certain physical finding but will certainly be a time- effective way of ensuring that all learners in a group experience the pertinent parts of the clinical examination of an individual patient. Evaluating a given residentís technique at physical examination might better be reserved for one-on-one teaching (eg, clinic or consultation rotations) or formal evaluation activities (eg, clinical evaluation exercise or objective structured clinical examinations). If evaluation at the bedside is desired, it may be less threatening to ask learners to describe physical findings rather than interpret them. Attending physicians might also minimize anxiety by coaching learners on specific examination techniques before entering the room. Discussing the findings of aortic insufficiency before adjourning to the bedside identifies learner deficiencies in advance. Finally, it may be helpful at the beginning of a rotation to have an open discussion about how physicians continuously learn from their patients.

HOSPITAL AND PATIENT FACTORS

Are the team’s patients concentrated on one ward, or are they spread throughout the hospital? The latter situation can result in more transit time between patients, waiting for elevators, and other periods of “down time” in teaching or patient care. When patients are all close to the conference room, it may be feasible to present a case or two, go to the bedside, come back for discussion, and visit another patient or two again later in rounds. When patients are dispersed, it is sometimes necessary to finish all oneís conference room activities (presentations, discussions, talks) and then conduct patient visits. Alternatively, one can “walk and teach”: present a case outside the room (or at the bedside), visit the patient, make some teaching points in the corridor, and go on to the next patient. However, then one must be sensitive to the fact that (1) learners may become fatigued when required to stand for 90 minutes or longer; (2) corridors do not lend themselves to long discussions or the use of a blackboard, viewbox, or other teaching aids; and (3) patient confidentiality can be easily breached in public spaces such as corridors and elevators. Since eager discussions surrounding patient care are so common, the team might want to establish explicit ground rules whereby members remind one another whenever inadvertent discussions of specific patients break out in public areas.

Shorter lengths of stay are becoming the rule rather than the exception, making it a challenge to synchronize attending physician’s rounds with the patient’s “free time” (ie, when the patient is not out of the room for tests, procedures, or consultations). If seeing certain patients together on rounds is essential (because of great teaching value), the student or intern can try ahead of time to make sure the patient is available for rounds.

Privacy concerns fall into three categories. First, there may be the issue of other patients in multioccupancy rooms. Although one can “pull the curtains” for parts of the physical examination, the presence of other patients in the room may constrain probing sensitive parts of the history, such as substance abuse, sexual history, depression, and family conflicts. Second, family or friends may be present. While this may be an opportunity to query them for additional information and to answer their questions, sometimes it may be necessary to ask them to leave temporarily to provide some private time with the patient. Third, a visit by the ward team itself is not exactly a private encounter. Although studies show that patients actually value these team visits,1-3,18 they do lack the intimacy of the traditional one-on-one doctor-patient relationship. Return visits by the attending physician may be necessary when emotional issues are uncovered, extensive patient education and counseling is required, or a detailed history and physical examination is warranted to clarify a case. Also, sessions with both patient and family are sometimes needed to discuss operations or procedures, informed consent, DNR status, nursing home placement, or prognoses of serious illnesses, such as cancer.

Physical barriers can impede bedside teaching, particularly physical examination. Common constraints include IV lines, catheters, or other tubes; physical restraints; hospital gowns or wound dressings; and the patient’s being indisposed (supine in bed, eating meals, on the telephone, using the bedpan, in the bathroom). Similarly, emotional and cognitive barriers-pain, sleep deprivation, fear, anger, depression, delirium, or dementia-can interfere with effective interviewing on teaching rounds.

OTHER ISSUES

The location of the attending physicianís office can indirectly affect bedside teaching during rounds. Is it in or adjacent to the hospital, or is it remote? If remote, it is more difficult to come back to the wards frequently between sessions of rounds, so that more direct patient care and visitations may be necessary during attending physicianís rounds. A second consideration is how much protected time the attending physician has when on the wards. If the attending physician still has a busy practice (community or hospital-based), heavy administrative duties, a research laboratory, or grant deadlines that cannot be put on partial hold for a month, the “free time” between rounds may be limited, and more work will need to get done with the team. A third related factor is the number of months per year that the attending physician is assigned to the wards. The physician who attends more frequently (eg, 3 months or 4 months per year) may find it more difficult to put things on partial hold, whereas the person who attends occasionally (1 or 2 months per year) may be able to defer some tasks for 3 weeks or 4 weeks, realizing there will be 6 months to 12 months to ìcatch upî before one has attending physician duties again. Finally, there are reimbursement and medicolegal issues. Increasingly, third-party payers are requiring a heavier attending physician presence in the charts and in visiting patients. The attending physician as pure teacher is giving way to one who must be more and more ìvisible.î Previously, this was particularly the case for patients on private teaching services, but it is now expanding to all hospitalized patients.

More and more, clinical teaching will occur in the ambulatory setting,24 and here too “bedside” teaching, ie, teaching when all three parties (attending physician, learner, and patient) are together, is both important and challenging. First, the clinic setting demands real-time teaching. The learner often has a number of patients to see and is thus on a tighter time schedule than on the wards. Also, the patient is often on a schedule, coming from and going back to home, work, or school responsibilities. Thus, time with the patient in the clinic must often be particularly focused and efficient. The number of patients actually seen together with learners can also depend on several other factors:

* Reimbursement issues:

Some payers require the staff/faculty member to directly see each patient seen by students or residents, even if briefly.

* Level of the learner:

With students, all patients are usually seen by the clinic attending physician, whereas with senior residents or fellows, only complex or teaching cases may be visited by the attending physician.

* Number of learners:

If the clinic attending physician must precept many learners, the time available to visit each patient will be limited.

* Amount of “protected time” for precepting:

Does the attending physician have no, a few, or many walk-in or scheduled patients of his own to see?

* Number and complexity of patients seen by the learner:

Is the learner on schedule, or running behind and in a hurry to catch up?

* Finally, multiple learners coming at the same time and having to stand in line can be a problem:

Attending physicians can sometimes triage by quickly answering easy questions or those from more senior learners. Also, one can occasionally take several learners to briefly see the patient, particularly for physical findings.

Clinical teaching is demanding enough with its unpredictability, service-education tensions, environmental distractions, and time constraints. Triangulating the teacher-learner relationship by incorporating a patientís own critical (and preeminent) needs amplifies the teaching challenges. What Joseph Epstein said of teachers in general aptly describes feelings that occur at the bedside: “I have never heard anyone whom I consider a good teacher claim that he or she is a good teacher-in the way that one might claim to be a good writer or surgeon or athlete. Self-doubt seems very much a part of the job of teaching: one can never be sure how well it is going.” Despite the uncertainties of teaching in the presence of the patient, medical interview and physical examination (rather than laboratory evaluation) still accounts for three fourths of our diagnoses, not to mention the humanistic essence of our profession. The longer we teach, the more we understand Osler’s conviction that “medicine is learned by the bedside and not in the classroom.”25

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

Agree

Disagree

Strongly Disagree

Not Applicable

I can recognize and list the benefits of bedside teaching for learners. Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applicable

I can describe strategies to effectively deal with various hurdles to the implementation of bedside teaching. Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applicable

I can recognize and list benefits of bedside teaching for patients. Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applicable

I plan to incorporate beside teaching into my instructional methods during the upcoming methods. Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applicable

This information will be useful in my teaching. Strongly Agree

Agree

Disagree

Strongly Disagree

Not Applicable

Post Test – Bedside Teaching
1. Preceptors observe learners in the clinical setting only to assess technical skills.
True False

2. To allow an unbiased observation of the learner’s clinical skills, preceptors must not participate in a learner-patient encounter.
True False

3. Preceptors should change their purpose for observing learners in the clinical setting the course of a clerkship/rotation.
True False

4. Preceptors should assign office staff to act as observers for learners and provide feedback to them.
True False

5. Preceptor feedback often provokes learners with anxiety and is not valued as an effective teaching method.
True False

6. If a learner is doing well, preceptors do not have to provide feedback to be effective.
True False

7. Preceptors should avoid feedback that tells learners what they ought to do and how they ought to do it.
True False

8. Preceptors should provide personal judgments on learner performance when giving effective feedback.
True False

9. Preceptors should provide immediate feedback to learners to enhance learning.
True False

10. Feedback and evaluation generally refer to the same process in the clinical learning environment.
True False
Preceptor Microskills
Learning Objectives

* Articulate the 7 microskills discussed in the module.
* Value “expectation setting” as an important part of the learning process.
* Give examples of questions that encourage a learner to make a commitment around a particular issue, articulating his/her opinions as the basis for the learning, rather than waiting to receive the conclusions of the teacher.
* Give examples of questions that will probe for deeper understanding of an issue in order to reveal knowledge deficits.
* Begin to reflect upon your own “general rules” that can be conveyed to learners while you teach.
* Value “reinforcing right behavior” as foundational to your role as a teacher and mentor.
* Intend to correct learner mistakes by allowing self-reflection and by offering supportive but direct feedback.
* Determine that you will take 5-10 minutes for reflection with learners at the end of a session in order to cement the learning.