Bedside teachingBedside teaching

Azim Mirzazadeh MDAzim Mirzazadeh MDAssistant ProfessorAssistant Professor

Division of General Internal MedicineDivision of General Internal Medicine

Department of MedicineDepartment of Medicine

Tehran University of Medical SciencesTehran University of Medical Sciences

TopicsTopics

Brief overview of:Brief overview of:

The benefits and challenges of bedside The benefits and challenges of bedside

teachingteaching

The strategies for improving teaching at The strategies for improving teaching at

the bedsidethe bedside

There should be ‘‘no There should be ‘‘no

teaching without the teaching without the

patient for a text, patient for a text,

and the best and the best

teaching is often that teaching is often that

taught by the patienttaught by the patientWilliam OslerWilliam Osler

1849-19191849-1919

Definition Definition

In modern times our definition of bedside teaching In modern times our definition of bedside teaching

(BST) includes any teaching done in the presence of (BST) includes any teaching done in the presence of

the patient, regardless of the settingthe patient, regardless of the setting

Therefore, it may occur in ambulatory clinic, inpatient Therefore, it may occur in ambulatory clinic, inpatient

ward or conference roomward or conference room

Current situationCurrent situation

Several surveys indicate that clinical teaching is moving

away from the patient’s bedside into conference rooms

and hallways

((Nair et al, 1997Nair et al, 1997))

Current situationCurrent situation

It is dishearting to realize that the time allotted to BST It is dishearting to realize that the time allotted to BST declined from 75% of teaching time 30 years ago to just declined from 75% of teaching time 30 years ago to just 16% by 1978 and is certainly much lower now16% by 1978 and is certainly much lower now

(El-Baghir, 2002)(El-Baghir, 2002)

Estimates of time actually spent at the bedside vary from Estimates of time actually spent at the bedside vary from 15% to 25%15% to 25%

(Ramani et al, 2003)(Ramani et al, 2003)

Why the bedside teachingWhy the bedside teaching

is so important? is so important?

BenefitsBenefits

Opportunity to:Opportunity to:

Humanizes care by involving patientsHumanizes care by involving patients Encourages the use of understandable Encourages the use of understandable

and non-judgmental languageand non-judgmental language

•gather additional information from the patient

•directly observe students’ skills•role model skills and attitudes

Benefits (con.)Benefits (con.)

Active learning process in which adults Active learning process in which adults learn bestlearn best

Patients feel activated and part of the Patients feel activated and part of the learninglearning

Improves patients’ understanding of Improves patients’ understanding of their disease and the work-uptheir disease and the work-up

What’s the opinion of different What’s the opinion of different

participants about BST?participants about BST?

Major participantsMajor participants

Bedside Teaching

patient

Faculty

trainees

FacultyFaculty

88% of attendings preferred that cases NOT be 88% of attendings preferred that cases NOT be presented at the patient’s bedside presented at the patient’s bedside

(Kroenke, et al. 1990)(Kroenke, et al. 1990)

47% of attending physicans who had practiced 47% of attending physicans who had practiced less than 10 years favored presenting and less than 10 years favored presenting and teaching away from the bedsideteaching away from the bedside

(Wang-Cheng, et al. 1989)(Wang-Cheng, et al. 1989)

FacultyFaculty

Of all respondents (120), 95% agreed or strongly Of all respondents (120), 95% agreed or strongly agreed that BST is an effective way to teach agreed that BST is an effective way to teach professional skillsprofessional skills

((Nair, et al. 1998Nair, et al. 1998))

TraineesTrainees 96% of residents preferred that cases NOT be 96% of residents preferred that cases NOT be

presented at the patient’s bedside presented at the patient’s bedside Respondents believed that only 30% of an Respondents believed that only 30% of an

attending's rounding time should be spent at the attending's rounding time should be spent at the bedsidebedside

(Kroenke, et al. 1990)(Kroenke, et al. 1990)

Only 2% of housestaff and 4% of students felt Only 2% of housestaff and 4% of students felt comfortable presenting cases at the bedside comfortable presenting cases at the bedside

(Wang-Cheng, et al. 1989)(Wang-Cheng, et al. 1989)

TraineesTrainees

100% of the students, interns and residents 100% of the students, interns and residents (N=136) believed bedside teaching was valuable (N=136) believed bedside teaching was valuable

Once they experienced it, over half said they did Once they experienced it, over half said they did not receive enough of itnot receive enough of it

((Nair, et al. 1997Nair, et al. 1997))

PatientsPatients 85% of patients preferred to be present when their cases were 85% of patients preferred to be present when their cases were

presented presented (Wang-Cheng, et al. 1989)(Wang-Cheng, et al. 1989)

68% found that it increased their understanding of their medical 68% found that it increased their understanding of their medical problemsproblems

77% said they enjoyed it (only 17% did not)77% said they enjoyed it (only 17% did not) 83% said it did not make them anxious83% said it did not make them anxious 85% said they do not think that bedside teaching breaches 85% said they do not think that bedside teaching breaches

confidentiality confidentiality 84% said they would recommend bedside teaching to other patients 84% said they would recommend bedside teaching to other patients

((Nair et al. 1997Nair et al. 1997))

ConclusionConclusion

We see that physicians have echoed some of our We see that physicians have echoed some of our

same initial reactions to bedside teachingsame initial reactions to bedside teaching

when bedside teaching is actually studied, when bedside teaching is actually studied,

patientspatients and and learnerslearners appreciate it and find it appreciate it and find it

effectiveeffective

ConclusionConclusion

It is time we stopped blaming patients It is time we stopped blaming patients

and students for our own insecurities and students for our own insecurities

at the bedsideat the bedside

Why the bedside teachingWhy the bedside teaching

is so sparingly used? is so sparingly used?

Barriers to Bedside Barriers to Bedside TeachingTeaching

Teacher-relatedTeacher-related

Teaching climate–relatedTeaching climate–related

System-relatedSystem-related

Patient-related Patient-related

MiscellaneousMiscellaneous

(Ramani et al. 2003)(Ramani et al. 2003)

Barriers to Bedside Barriers to Bedside TeachingTeaching

Declining bedside teaching skills

Inexperience with bedside teaching

Bedside aura

Lack of control

Difficulty in engaging all team members

Lack of motivated teachers

View held by some that bedside teaching should be done

by more junior educators such as residents

Teacher-related

Barriers to Bedside Barriers to Bedside TeachingTeaching

Time constraints

Lack of faculty training in bedside skills

Lack of rewards for teaching

Lack of teaching role models in faculty’s own training

Teaching climate–related

Barriers to Bedside Barriers to Bedside TeachingTeaching

Interruptions (phone calls, visitors, pagers)

Short patient stays

Too much technology

System-related

Barriers to Bedside Barriers to Bedside TeachingTeachingPatient-related

Perceived patient discomfort

Ill patient

Absent patient

Patient misinterpretation of discussion

Patient privacy issues

Uncooperative/angry patient

Change in patient profile

Large crowd in small room

Noisy wards

No blackboard or x-ray view boxes for discussion

Inability to refer to textbook

Teacher and learner hesitation in discussing differential

diagnoses

Fear of undermining housestaff

Learner fatigue

Miscellaneous

Barriers to Bedside Barriers to Bedside TeachingTeaching

Strategies for improving Strategies for improving BSTBST

Improving bedside teaching skills of faculty

Diminishing the aura of bedside teaching

Enhancing the value of teaching

Establishing a teaching ethic

(Ramani et al. 2003)(Ramani et al. 2003)

Model of Best BST PracticesModel of Best BST Practices

Domain I. Attend to Patient’s Comfort

Domain II. Focused Teaching

Domain III. Group Dynamics

(JANICIK & FLETCHER, 2003)

Model of Best BST PracticesModel of Best BST Practices

Ask ahead of time

Introduce everyone to the patient

Brief overview from primary person caring for patient

Explanations to patient throughout, avoid technical language

Base teaching on data about that patient

Genuine, encouraging closure

Return visit by a team member to clarify misunderstandings

Attend to Patient’s Comfort

Model of Best BST PracticesModel of Best BST Practices

Microskills of teaching:

Focused Teaching

Diagnose the patient

Diagnose the learner

Targeted teaching

ObserveQuestion

Role modelPracticeTeach general conceptsGive feedback

Model of Best BST PracticesModel of Best BST Practices

Limit time and goals for the session

Include everyone in teaching and feedback

Group Dynamics

Take home messageTake home message

Bedside clinical teaching, an essential tool for learning, is

practised less frequently nowadays

Students, trainees and teachers fully support this activity

There are different types of barriers to bedside teaching

We need to be more familiar with these barriers in our

institutions and find the solutions to increase the role of

BST

Suggested readingsSuggested readings

Ramani S. “Twelve tips to improve bedside teaching.” 2003. Ramani S. “Twelve tips to improve bedside teaching.” 2003. Med TeachMed Teach. 25(2): 112-115. (provided). 25(2): 112-115. (provided)

Janicik RW, Fletcher KE. “Teaching at the bedside: a new Janicik RW, Fletcher KE. “Teaching at the bedside: a new model.” model.” Med TeachMed Teach. 2003. 25(2): 127-130.. 2003. 25(2): 127-130.

Ramani S., et al. “Whither Bedside Teaching? A Focus-group Ramani S., et al. “Whither Bedside Teaching? A Focus-group Study of Clinical Teachers. Study of Clinical Teachers. Acad Med. Acad Med. 2 0 0 3.2 0 0 3. 78 (4)78 (4)

Medicine is Medicine is

learned by the learned by the

bedside and not in bedside and not in

the classroomthe classroom

William OslerWilliam Osler

1849-19191849-1919

Thank youThank you