ResidentEducatorDevelopment

The RED ProgramA Residents-as-Teachers CurriculumDeveloped by Heather A. Thompson, MD

The RED Program• Team Leadership• How to Teach at the Bedside• The Microskills Model: Teaching during

Oral Presentations• How to Teach EBM• The Ten Minute Talk• Effective Feedback• Professionalism• Patient Safety and Medical Errors

Teaching at the Bedside

Resident Educator

Development (RED) Program

“Medicine is learned by the bedside and not in the classroom. Let not your

conceptions of disease come form words heard in the lecture room or read from a book. See, then reason and compare and

control, but see first.” Sir William Osler

An exercise• Recall a bedside teaching session

that was effective. What made it go well?

• Recall a bedside teaching session were learning was minimal. What made this session ineffective?

Why Teach at the Bedside?

Why Teach at the Bedside?

• Reinforces skills of medical interviewing, communication, and patient education.

• Opportunity to observe, teach, and practice physical exam skills.

• Contributes to a greater understanding of patient’s needs.

Why Teach at the Bedside?

• Sets the tone for professional interaction between patients and teams in a teaching hospital.

• Often the first encounter with “real live” patients for the medical students.

• You need to see and examine your patients every day; may as well make the most of the encounter!

Is there data?

• Survey of Australian Medical Students and Residents:

--99% agreed that bedside teaching was valuable and effective for teaching PE skills --HOWEVER only 53% stated they had enough bedside teaching to improve their PE skills--Medical Education Sept 1997 31(5): 341-346

Is there data?

• Actual time spent at the bedside is decreasing: 15-25% of total time on wards

• Attendings at the bedside a frequency of once every 2-4 days

Annals Int Med 1997 126 (7): 217-220JAMA 1986 256:725-739J Med Educ. 1982 57:854-859

Is there data?

• Survey in JGIM:--88% of attendings prefer that cases NOT be presented at bedside

• Survey out of MCOW: --only 2% of housestaff and 4% of students feel comfortable presenting at bedside

• Why is this happening?

Barriers

• Focus groups at Boston University have identified barriers to bedside teaching, broken down by category. Academic Medicine April 2003 78(4):384-390

Teacher-Related• Inexperience with bedside

teaching• Lack of confidence in physical

exam skills• Performance pressure

Teacher-Related• Lack of control over situation• Difficulty in engaging all team

members

Teaching Climate-Related• Time constraints: too many

patients to see on morning rounds, limited time for H&P

• Lack of training in bedside skills

• Lack of teaching role models

Systems-Related• Too many interruptions (phone calls,

visitors, lab draw, trip to radiology)• Shortened patient stays: average

length of stay is 3 days• Technology: overabundance of data

to discuss (scans, lab tests) rather than the patient’s symptoms and physical exam signs

Patient-related (perception vs. reality?)

• Patients not comfortable being discussed by a large team

• Patient too medically unstable to cooperate with history or exam

• Absent patient• Patient misinterpretation of

discussion • Uncooperative/angry patient

Miscellaneous• Learner fatigue, boredom• Fear of being called upon • Privacy Issues (HIPPA)• Physical environment:

--large crowd in a small room--no blackboard/Xray view box

--inability to refer to textbook, computer resources, lit seach

General Strategies• Improve Your PE skills

--Working up patients--Program Workshops --Physical Diagnosis Textbooks, CDs--Professor’s Rounds/Chief Resident Rounds--Mini-CEX: an observed physical--Participating in an OSCE

General Strategies• Diminish the aura of bedside teaching

“You may not be an expert but you still know a fair amount…even as a junior clinician. You can’t get everything, but you can still get more than you did as a third year student.”--Boston U Focus Group Participant“You don’t need gray hair (or lack of hair) to teach at the bedside.”--Former U Chief Resident

General Strategies• Use laptops or PDAs at the bedside

--Lit searches/EBM--UptoDate--Info Retriever--Clinical prediction rules, likelihood ratios, pos predictive values

General Strategies• Realize that most patients enjoy

bedside teaching rounds--77% found the experience

enjoyable --68% found that it increased their understanding of their medical problems (NEJM 1997 336:1150-5)

Before Encounter: Prepare

• Formulate specific goals and objectives for each session.

• Read up on the topic/technique.• Choose the patient wisely.• Orient the patient to the purpose

and format.

Before Encounter: Teaching considerations

• Discuss what one might expect to find on PE in certain disease states.

• Discuss how to elicit these PE findings. (demonstrate on a volunteer)

• Discuss sensitivity/specificity, PPV/NPV

During the Encounter: Patient considerations

• Begin and end with the patient.• Opening lines: “Tell us what

brought you in the hospital.” “Can you describe how you are feeling today?”

• Close with: “What questions do you have for us?” “What is it that you want most from the doctors caring for you?”

During the Encounter: Patient considerations

• Try to have as many people SEATED in the room as possible during the initial interview.

• Explain to the patient during rounds when you are going to use medical jargon, or avoid shoptalk altogether.

During the Encounter: Patient considerations

• Be careful about listing a differential diagnosis, such as “cancer”.

• Avoid asking a question of the group that they might not be able to answer: undermines patient confidence.

During the Encounter: Teaching considerations

• In a larger group: shift from open-ended (“listen to the heart and tell me what you hear”) to directive (“listen with the diaphragm at the LUSB where you will hear a blowing diastolic murmur consistent with aortic insufficiency”)

During the Encounter: Teaching considerations

• Goal is to gain some experience with a certain PE finding as opposed to evaluating learner’s technique

• Establish a comfortable environment (it’s OK to say “I don’t know” or “I don’t hear it”)

After: Debrief• The group should leave the

bedside, and observations are made as to what was seen.

• Learners should have time to ask questions, and give and receive feedback.

Admitting a Patient• One on one, with your intern or student

--helps to be the “Fly on the Wall” (observer) or the “Midwife” (lets the process happen, intervenes at critical moments)--Again, review beforehand what PE findings you might expect --This is the opportunity to assess learner’s specific skills or technique, give feedback

Admitting a Patient• With your student

--Often, they want to know “how much” of the PE needs to be done--Remember, in 2nd year medical school an exhaustive 2+ hour exam is taught--Students need to learn how to tailor the exam to the presenting problem--They also want to know how to “remember” all the elements of the admit H&P

Admitting a Patient• Medical Student Strategies

--Refer to templates.--Can teach the “top down” or “head to toe” approach by body areas: general appearance, HEENT, Heart, Lungs, Abd, Extremities (peripheral pulses/edema/joints), Skin, Neuro. --Expand on any one area based on symptoms or abnormal findings.

(FYI: 8+ covers billing, too)

Daily Work Rounds• Again, always consider the patient

--Sitting down patient overestimates time spent with MDs

• Opportunity to model communication skills/“bedside manner”

• Review new or fixed findings with other team members

• Can review or demonstrate a specific technique

Video Exercise• View the bedside teaching rounds

represented in this video vignette• Discuss what went well, and what

could be improved upon

In summary• Go to the bedside with a specific

purpose• Teach PE skills when the

opportunity arises• Model communication skills• Maintain a comfortable and

positive environment for the patient, learners, and you

In summaryThere should be “no teaching without a

patient for a text, and the best is that taught by the patient himself.” --Sir William Osler