Whither bedside teaching?

Observe, record, tabulate, communicate.  Use your five senses.  Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone you can become expert.  Medicine is learned at the bedside and not in the classroom.  Let not your conceptions of disease come from words heard in the lecture room or read from the book.  See, and then reason and compare and control.  But see first.

-Sir William Osler

I recently received my quarterly faculty evaluation.  I usually take a cursory look into the scores and file the report away for future reference.  On occasion, the residents take the time to write some useful comments that help me to become a better teacher.  I was a little surprised by such a comment with this evaluation:

"Please do not ask the resident medical questions in front of patients, wait until we have exited the room."

In my practice, I find it exceedingly difficult to go to the bedside with my learners.  I often fall victim to the nursing station presentation as I hurry off to see other patients.  Despite this, I make the occasional effort to get to the bedside with my residents and students.  As Osler points out, the best learning is that which is done at the beside with a patient.  While less frequent than I desire, these encounters are fulfilling as a teacher and really allow me to see my learners in action.

Perhaps that is why I find the above comment troubling.  Have we abandoned the bedside for so long that our learners are so uncomfortable in front of patients with a teacher?  Are they so afraid of appearing to be wrong when asked more advanced questions?  I can respect their fear.  I've been there.  I have also learned far more from being wrong and making mistakes.  It's simply part of being a learner.   

Reflecting upon the comment, I decided to pull out one of my favorite articles on bedside teaching and review some tips for making it work.

Before going to the bedside:

Prepare: Formulate goals, know learning needs of your students and residents

Orient learners: Learners should know what is expected before going in.  I guess I have failed to explain to them that it is okay to be wrong.  Uncomfortable, yes, but still okay.

Orient Patients: Let the patient know everyone and their role; they should already know the learner.  Explain that you'll be asking some medical questions and make sure to thank them for their role in teaching the learner

At the Bedside:

Establish the environment: Try to make the atmosphere comfortable.  I try to keep the discussion less formal.  I'll ask some clarifying questions of the patient and then focus on the learners.  The key is to challenge them intellectually without humiliating them.  

Respect learners and patients: Be human.  You must remain sensitive to the patient and how illness affects them.  I do find that patients enjoy learning at the same time as the learners.  Often, the medical discussion forces me to really focus on communicating the same information to the patient in a manner that they can understand.

Engage everyone: Often not a problem where I practice; usually it is just one learner, but if you teach in a setting with a lot of learners, make sure you have questions for all, from the beginning medical student to the PGY-IV resident.

Involve the patient: Make sure to allow the patient to correct unclear parts of the history.  Make sure that they're able to ask questions as well.

Match teacher and learner goals: This topic fits into the "before" category as well.  I try to start my shift by asking my learners what their goal for the day will be.  This allows me to cater the learning to their needs and wants.  With residents, I'm also able to cater to their deficiencies since I work with them often.

After leaving the bedside:

Debrief:  This has 2 purposes: clarify the encounter and plan and to provide feedback.  The learner gets some time for questions, we finalize our workup plan, and then I can provide brief feedback on how to improve.

While bedside teaching is underutilized, with practice it is one of the best clinical teaching tools.  We all have something to offer to our learners, sometimes skills that can only be learned through observation, practice, and reinforcement at the bedside.  Unless we go there and face our (and our learners) discomfort, we cannot begin to realize our full potential.

Reference:

Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med. 2003 Apr;78(4):384-90. PMID: 12691971