Teaching at the Bedside
This monograph was developed by the MAHEC Office of Regional Primary Care Education, Asheville, North Carolina. It was developed with support from a HRSA Family Medicine Training Grant. The monograph was provided to our Office of Faculty Development with permission to modify and use in our faculty development program.
Teaching at the bedside is defined as teaching in the presence of the patient. Sometimes thought to be applicable only to the hospital setting, bedside teaching skills apply to any situation where the teaching occurs in the presence of the patient, including the long-term care facility and the office setting.
Teaching at the hospital presents additional challenges and opportunities for the preceptor. The hospital preceptor is often working with a team of learners and frequently has inadequate facilities for teaching. On the other hand, the hospital setting also provides opportunities to expose the learner to a body of knowledge and skills that cannot be taught the office.
This monograph has been developed to explore issues related to teaching at the bedside and review teaching techniques and tips for all who find themselves at the bedside with patients and learners.
The goals for this monograph are to:
- Review past and recent history of bedside teaching.
- Discuss the advantages and challenges of teaching at the beside.
- Explore strategies for improving teaching at the bedside.
- Review techniques for bedside teaching in the office setting.
Teaching at the Bedside: Past and Present
The importance of bedside teaching has been discussed throughout the history of medicine.
Like the modern preceptor, Hippocrates (460-370 BC) was not only a teacher but also an itinerant practitioner. The first two principles of his Hippocratic method are:
- Observe all, and
- Study the patient rather than the disease.
Although his exact methods of teaching are not known, it is difficult to imagine how the importance of these principles could be communicated unless patients were not present during these teaching encounters. The importance or observation and considering the patient and not just the disease are as relevant today and are still best taught in the presence of the patient.
Sylvius (1614-1672), a French practitioner for whom the Sylvian Fissure was named, was one of the first to record his thoughts on teaching on rounds:
"My method (is to) lead my students by hand to the practice of medicine, taking them everyday to see patients in the public hospital, that they may hear the patients symptoms and see their physical findings. Then I question the students as to what they have noted in their patients and about their thoughts and perceptions regarding the causes of the illness and the principles of treatment."(Whitman, 1990: 23)
More recently, Sir William Osler (1849-1920), a renowned clinician and teacher in Canada, England and the United States, became a strong proponent of teaching on rounds and stressed the importance of teaching at the bedside. In 1903 he stated, "How can we make the work of the student practical ? The answer is, take him from the lecture room, take him from the amphitheater put him in the outpatient department put him in the wards." He also expounded that there should be "no teaching without a patient for a text, and the best is that taught by the patient himself." (Whitman, 1990)
With this historical support for bedside teaching, where are we now? A study in 1964 indicated that less than 20% of teaching on rounds was done in the presence of the patient. In 1978 a similar study demonstrated a decline to 16% of teaching done at the bedside. Given the challenges of modern medicine with shortened hospital stays, increased acuity of illness in the patients and new requirements for oversight and documentation, it is doubtful that the amount of teaching at the bedside has increased. The conference room, nurses station or corridor have become the de facto location for teacher/learner interactions at the hospital.
History makes it clear that teaching at the bedside has been a vital component of medical training. We should strive to make it as productive and valuable as possible and to convey the energy and excitement of these past shapers of the profession.
Teaching at the Bedside: Obstacles to Bedside Teaching
If bedside teaching is valuable and important, why does it appear to be declining? A study of potential obstacles (Nair, Coughlan, & Hensley, 1998) revealed that time was considered to be the most significant factor interfering with bedside teaching. Pressures to see more patients, shortened hospital stays and competing demands for increased documentation are contributing to this decline.
Preceptors may avoid beside teaching because of concern for patient comfort, yet research has shown that a majority of patients enjoy and benefit from bedside teaching (Nair, Coughlan, & Hensley, 1997; Simons, Bailey, & Zwillich, 1989; Wang-Cheng, Barnas, Sigmann, Riendl, & Young, 1989). When conducted with sensitivity and respect, teaching in the presence of patients can add to rapport and communication.
Learners feel that the bedside is an excellent place to learn a wide variety of skills and often value this teaching more highly than their teachers (Nair et al., 1998).
Many teachers may feel uncomfortable in the role of bedside teacher. Lack of experience, unrealistic expectations and discomfort with teaching in the presence of the patient can lead to a reluctance to teach at the bedside. As will be discussed later, there are techniques and approaches that help make bedside teaching more efficient, fun and effective.
The Many Tasks of Rounding
The bedside is an important location for teaching, but it is not appropriate for all rounding functions. There are numerous functions that need to occur during rounds (see Table 1). Detailed discussion of differential diagnosis or care plan options is best done in a more confidential location. Administrative details and chart work will go more smoothly in a comfortable location away from interruptions.
Presenting patients is usually bet performed away from the bedside. Presentations done in the presence of the patient need to be sensitive to the patient and understandable by the patient. The typical format of patient presentation with its medical jargon may intimidate or confuse a patient.
Mini-lectures or detailed discussions of differential diagnosis will almost always include terminology or information that may be confusing or difficult for the patient to understand.
As attending you will be visiting all patients and this is a prime opportunity for role-modeling and bedside teaching. Although there is additional opportunity for teaching and role modeling in interactions with families this can disrupt a more formal planned teaching experience. Judgement is needed on how to incorporate discussions with family members into teaching.
|TABLE 1: Tasks on Rounds
Teaching on Rounds: The Conference Room
Since all rounding functions are not appropriate for the bedside, the conference room or nurses station is increasingly utilized. There are advantages and disadvantages to the use of this location as listed in Table 2. There are also specific strategies to get the most from this teaching.
As stated previously, time is the greatest obstacle to teaching, and if time spent in the conference room or nurses station is not budgeted well, there will be little time left for teaching in any other location. It is important for the teacher to direct the focus of the discussion and keep the flow of the many tasks moving.
The teacher must fulfill two roles simultaneously. While listening to a presentation or discussion, you are diagnosing the patients condition based on the data presented. At the same time also you need to diagnose the learner his/her strengths, weakness, omissions and areas for improvement. Recognizing and remembering this dual role is half the battle. One technique is to take two columns of notes during a presentation. In one column list of diagnoses and issues related to the patient, and in the second column list issues related to the learner, the presentation, differential diagnosis and care plan. This note-taking method will facilitate both of your roles as well as providing a record of learning and patient care issues to address.
Carefully noting patient care and learner issues as they arise will also help identify "teachable moments." Although any piece of information can be presented to a learner at any time, the impact of this teaching is enhanced if it relevant to the clinical situation at hand. For example, the role of magnesium deficiency as a cause for refractory hypokalemia can be discussed at any time, but when a patient with hypokalemia is identified, this clinical tidbit is much meaningful and more likely to be remembered. A quick note on your paper can help you to take advantage of this opportunity.
The conference room is perhaps the best place to focus on clinical problem solving. Discussion of an expanded differential is best done away from the patient, where it could be confusing or frightening to the patient. Even if a patient presents with a clear-cut diagnosis, the discussion can be enhanced by "What Ifs". By changing aspects of the case, you can exercise the clinical reasoning of the learners and help them to consider a larger differential. For example, if a patient with an asthma exacerbation is admitted, the discussion could be expanded to include pulmonary embolus by asking, "What if this patients left calf was swollen and tender? How would that change your differential diagnosis and evaluation?" This type of brief discussion can add interest to "routine" cases and foster improved clinical reasoning and allow discussion of additional clinical entities.
The conference room or nurses station also allows the teacher to role model the use of additional sources of information. Pharmacy colleagues, social workers and nursing staff can be sources of valuable information and sometimes will attend rounds regularly. Asking appropriate questions of these care team members can foster and interdisciplinary approach for the learner. A frequent problem with learners is that they feel they must carry all medical knowledge in their heads. The preceptor can role model the appropriate use of texts, journals and computerized sources of information to foster adult learning and comprehensive care.
|TABLE 2: Teaching in the Conference Room
Teaching on rounds involves spontaneity. Often one does not know in advance what issues or diagnoses are likely to arise. No one can be expected to speak extemporaneously on all possible topics. When an important issue arises that may benefit from a mini-lecture, reserve some time the next day to for a brief review. You may also assign a topic to a learner to present to the group at your next meeting.
Teaching on Rounds: The Corridor
It may seem that the corridor or hallway provides a location for rounding functions that are best not performed in the presence of the patient, while allowing ready access to the patient. Many teaching hospital hallways are clogged with clusters of learners craning to hear a case presentation while straining under a load of charts and dodging medicine carts and stretchers. At times these rounds can stretch on for hours and at their worst may be referred to by the learner as "shifting dullness" (after the physical finding related to ascites). At their best corridor rounds remain uncomfortable and at very high risk for violating the patients confidentiality.
|TABLE 3: Teaching in the Corridor
In general the use of the corridor should be limited. While trying to increase your bedside teaching you may find that brief hallway discussions are necessary, but an awareness of confidentiality should be maintained at all times.
Teaching at the Bedside
Teaching in the presence of the patient has several advantages. The presence of the patient strengthens the learning possibilities. As opposed to listening to a presentation or reading off a blackboard, learners have the opportunity to use nearly all of their senses -- hearing, vision, smell, touch to learn more about the patient and their problems. The sterile facts and descriptions from a sterile presentation come alive and are tangible. These characteristics alone can help the learner remember the clinical situation. I suspect that you might be able to vividly recall certain patients that you saw early in your training: the first patient you admitted with diabetic ketoacidosis the fruity smell of the breath, the air hunger of Kussmaul respirations, the decreased skin turgor. These experiences create hooks upon which a great deal of clinical learning can be hung for long-term storage and ready recall.
The presence of the patient allows for clarification of the history and physical. The case presentation is the result of a great deal of processing and interpretation by the learner. The bedside visit allows the teacher to clarify and confirm key aspects of the history and physical. Was the presentation of the characteristics of the patients pain accurate? Was an abdominal bruit present in this patient with a hypertensive emergency? Confirming this data is crucial to patient care but also provides an important chance to mold the learners clinical skills if performed in their presence.
Bedside teaching is very well suited for using role modeling as a teaching technique. Although it is possible to describe and discuss how to ask a question well or how to demonstrate sensitivity to a patients comfort and concerns, it can be far more effective to demonstrate those skills and techniques in front of the learner. The learner may be more apt to do as you do than as you say, and the positive results from good rapport and technique speak for themselves.
There are some perceived disadvantages to bedside teaching. There is no question that it takes more time. Given how effective it is a s a teaching strategy, what can you do to find time to teach at the bedside. One strategy is to avoid duplication. If an issue related to the history or physical exam comes up in the conference room, save that time for a bedside visit. If you are going to see a new admission after the conference room session, bring at least one learner with you. We will discuss more strategies on how to incorporate bedside teaching into a busy day in a later section. The truth remains that if you want time to do bedside teaching you will need to actively plan for it.
A concern for patient comfort is often expressed when discussing bedside teaching. Several studies have shown that a majority of patients enjoyed the experience and felt that they understood their problems (Nair et al., 1997). It seems certain though that patient comfort is dependent upon what is done at the bedside and how it is done. Table 5 lists several strategies to foster patient comfort during bedside teaching (Weinholtz & Edwards, 1992).
|TABLE 5: Patient Comfort Issues
If possible, one should provide the patient with advance notice of a bedside visit with a brief discussion of its purpose and what to expect. The time spent at the bedside should be limited, probably to 15 or 20 minutes as a maximum. The teaching session can be very tiring for the patient, especially since hospitalized patients are more acutely ill now than they have been in the past.
All procedures that are to be performed should be explained to the patient, even something as simple as a heart exam. In addition any discussion or communication about the patient should be understandable by the patient and should be explained to the patient. For this reason, one should avoid presentations at the bedside. Presenting about the patient in the third person can be demeaning and confusing for the patient. Extensive theoretical discussions may be very difficult to explain to the patient.
The bedside is an excellent place to teach history taking and physical exam skill. An additional skill that is often neglected is observation. Important clues to the patients illness, disease, or response to being hospitalized may often be found in the room or at the bedside. Snacks on the bedside table of the diabetic, blood streaked sputum in the emesis basin of a patient with cough and weight loss, or a pamphlet on the Jehovahs Witness religion on the bed table can shed important light. The bedside visit is the time to teach and practice careful observation.
Bedside teaching is more efficient and effective when done with a specific purpose in mind. Use the list you created in the conference room to identify the issues you which to review with the patient or physical exam findings you wish to confirm. What teaching opportunities are presented? Limiting the focus of the bedside visit will help control the time spent and make the visit more efficient.
After the teaching session is concluded, a learner or the teacher should return briefly to see the patient to answer any questions that may have arisen as a result of the visit and to thank the patient for their time and assistance.
It is important to maintain a comfortable environment for all participants. As discussed, the patients comfort is a vital consideration. The bedside visit is also not the place for pointed questioning or criticism of learners. This should be a place for positive learning. By the same token you should feel as comfortable as possible in your role as bedside teacher. Avoid teaching topics that you are less comfortable with. Use the skills and attitudes that come naturally to you most often, and gradually hone and add new skills with repeated visits to the bedside. It is said that an episode of bedside teaching is successful only when everyone involved feels better afterward patient, learners and teacher (LaCombe, 1997).
Bedside Teaching: Getting Started
At this point we hope that you see the unique value of the bedside as a site for teaching. If you are already doing some bedside teaching we hope that you have inspiration and ideas on how to improve your teaching. If you dont already do some bedside teaching, the primary obstacle is to get started. Dont set unrealistic expectations. You may not have the luxury of a full half-day spent moving from one stimulating clinical case to another accompanied by a group of enthusiastic and appreciative learners. The key to doing more bedside teaching is to start small.
First, budget some time for going to the bedside. Find a time when you are going to be seeing a patient anyway and make this visit a teaching visit by bringing one or more learners and entering the room with a purpose. Even if you can only do it once or twice a week, you have opened the door. This may add a little time to that normally spent with the patient but could provide a significant learning experience.
You may look at your patient list and feel that there are no interesting teaching opportunities. Diagnoses that may seem old hat to you may new for your learner. All patients, whatever their diagnosis, have histories and physical findings. A review of a good normal exam can be valuable from time to time, and physical findings unrelated to the diagnosis (a benign seborrheic keratosis, a torus palatini, or an accessory nipple) could be exciting for a learner. More routine cases are a good time to strengthen observation skills. There is teaching and learning in any encounter.
If you are working with a team of learners, you do not need to have the entire patient care team with you to do bedside teaching. Take one learner with you to see a new patient whom she/he has admitted. Ask another learner to accompany you when you need to discuss a case with a family after rounds are completed. These less formal instances are still bedside teaching and can be very valuable.
All the responsibility need not fall to you alone. Get your learners involved in selecting and presenting patients. Inform learners that they will be asked to point out three physical findings on a patient on bedside rounds the following day. Inform a skilled learner in advance that you would like him or her to demonstrate a specific technique at bedside teaching rounds. Have learners select the focus for a bedside visit or conduct a bedside visit for their peers.
In modern medicine we are less reliant on our physical exam skills, and as a result they are less finely honed. Bedside teaching is an opportunity for the preceptor to focus more energy on these clinical skills. It may require some brushing up so start small. Select and area of interest and read a little. Dust off your med school text on physical diagnosis and stash it at the nurses station or in the conference room for ready reference for you and the learners. Some additional focus and bit of practice will polish up those skills quickly.
|TABLE 6: BEDSIDE TEACHING: Getting Started
Teaching at the Bedside: The Office Setting
There are significant opportunities for teaching in the presence of the patient in the office or ambulatory setting. In the typical interaction, the learner sees the patient first, presents the patient to the preceptor outside of the exam room and then both return to the room to complete the visit. One can vary this order and of these components allows chances for bedside teaching.
Although typically the learner sees the patient first, seeing the occasional patient together can allow an opportunity for significant role modeling. Although shadowing is usually considered a technique for early learners, it may be judiciously employed with more higher level learners to demonstrate advanced techniques of managing the visit, advanced questioning and dealing with multiple problems presented by the patient. The out-patient preceptor can often predict the challenges that certain patients will offer and can discuss in advance the goals and strategies planned for the encounter so that the learner can be actively analyzing the interaction.
|TABLE 7: OUT-PATIENT BEDSIDE TEACHING
PRESENTING IN THE PRESENCE OF THE PATIENT
THE VISIT WRAP-UP
As discussed in rounding techniques, it is possible to have the learner do their presentation in the presence of the patient. This technique requires some preparation. The learner should already be fairly adept at presentation and should be informed in advance that this technique will be used. She/he should be encouraged to use terms that are likely to be understood by the patient. The patient should be instructed to be an active part of the presentation, clarifying or correcting parts of the presentation as appropriate. Presenting at the bedside requires careful patient selection but can be an efficient, useful and enjoyable technique.
Returning to the room to complete the visit invites the use of a variety of techniques. The learner may be given the opportunity to ask additional questions or clarify points that arose in the discussion of a presentation. This provides the preceptor to observe immediately how the learner responds to feedback and advice. Role modeling of the doctor patient relationship is a valuable component of the wrap up portion of the visit. The learner can be given the opportunity to provide medication or patient education, allowing the preceptor to observe these skills. As at the bedside it is important to thank the patient for their help and their contribution to teaching.
Teaching at the Bedside: Conclusion
Bedside teaching has a long and venerable history and with good reason. Teaching in the presence of patients provides unique and valuable opportunities to integrate the knowledge and skills of medicine for the direct benefit of the patient. The teacher is able to role model skills and attitudes which are vital, but which are hard to communicate with words. Modern medicine has placed additional demands on all parties involved, but that is insufficient reason to abandon a teaching tradition that spans several millennia. We must renew and increase our efforts to pass on this tradition of medical education.
Wang-Cheng, R. M., Barnas, G. P., Sigmann P., Riendl, P. A., & Young, M. J. (1989). Bed side case presentations: Why patients like them but learners don't. Journal of General Internal Medicine, 4, 284-287.
Whitman, N. (1990). Creative Medical Teaching. Salt Lake City: University of Utah School of Medicine.
Sapira, Joseph D. (1990). The Art and Science of Bedside Diagnosis.
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Degowin, E. L., & Degowin, R. L. (1994). Diagnostic Examination, 6th
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Bates, B. (1995). A Guide to Physical Examination, 6th Ed.
Whitman, N., & Schwenk, T. L. (1997). The Physician as Teacher, 2nd Ed. Salt Lake City: Whitman Associates.
Related Preceptor Development Program Topics
The Effective Preceptor
Teaching Styles/ Learning Styles