Bedside Teaching

Jennifer L. Peel, Ph.D.

Director of Education, Office of Graduate Medical Education Assistant Professor, Anesthesiology Educational Development Specialist, UTHSCSA Division of Educational Research & Development

There should be no teaching without a patient for a text, and the best teaching is that taught by the patient himself.

Osler, 1903

What are the advantages of teaching with the patient present?

Advantages of Teaching with the Patient Present

1. The patient can be seen as an individual, with whom medical decisions are made, rather than to whom procedures and tests are applied, thus humanizing and personalizing medical care.
Linfors & Neelon, 1980

2. The presence of the patient helps the teaching process to be more participative, such that teachers and learners together have the collegial opportunity to understand the patients problems and find ways to solve them.
Linfors & Neelon, 1980

3. Bedside teaching is the ultimate manifestation of the physician as teacher, rather than as lecturer, discussant, or consultant. This role modeling behavior is critical to the students professional development.
Linfors & Neelon, 1980

4. Bedside teaching is essentially the only method in which the teacher has the opportunity to observe patient care skills directly and give immediate feedback.

What are some of the barriers to bedside teaching?

Barriers to Teaching at the Bedside

1. A false concern that teaching which involves the patient may upset or disturb his/her comfort and well-being

Linfors & Neelon, 1980

Evidence
Lehmann, et al. (1997) Linfors & Neelon (1980) Nair, et al. (1997)

2. Concern by some physicians that patients should not be involved at all in medical discussions, even through bedside teaching

Linfors & Neelon, 1980

3. The belief by some physicians that medical education should always consist of the direct transmission of knowledge from the active teacher to the passive learner
Linfors & Neelon, 1980

Levels of Cognitive Learning

Evaluation
Synthesis Analysis Application

Comprehension
Knowledge
Bloom, et al., 1956

4. The desire of some teachers to limit their discussions to the technological and biomedical aspects of medical care, particularly to the area in which they feel expert
Linfors & Neelon, 1980

5. The concern that house staff are tired and unmotivated

Janicik & Fletcher, 2003

6. The fear that some teachers may lack the necessary complex interactive skills to lead an elegant, erudite, and compassionate Oslerian-type discussion
Linfors & Neelon, 1980

How Do We Overcome the Barriers?

Physician
Teacher
Trust Respect Transfer of information and emotion

Patient
Learner

How Do We Overcome the Barriers?

Educational Golden Rule:

The teacher should treat the student as the teacher would have the student treat the patient.

Bedside Teaching Model

Three Domains
1. Attending to patient comfort-remain patient centered and respectful
Establish rules for conduct Ask the patient ahead of time Introduce all Provide a brief overview Avoid technical language Teach with data about the patient Provide a genuine, encouraging closure
Janicik & Fletcher, 2003

Bedside Teaching Model

2. Focused teaching-conduct an effective teaching session in a focused manner that is relevant to an individual patients and learners needs
Diagnose the patient Diagnose the learner
Target the teaching Provide constructive feedback (privately)
Janicik & Fletcher, 2003

Effective Feedback

Research on feedback recognizes the importance of credibility

You will be perceived as credible by medical students and others if they see that you call em the way you see em.

Cathcart & Samovar, 1989

Effective Feedback

Research on feedback supports the notion that it is important to demonstrate responsiveness

You will be perceived as responsive by medical students and others if you begin with the learner.
Cathcart & Samovar, 1989

Effective Feedback

Research on feedback emphasizes the key role of trust

There is some evidence that trust is enhanced when you sandwich the negative feedback between the positive.

Cathcart & Samovar, 1989

EGO Sandwich

Positive

Negative Positive

Effective Feedback

Timing is critical

Without feedback, mistakes go uncorrected, good performance is not reinforced, and clinical competence is achieved empirically or not at all.
Ende, 1983

Bedside Teaching Model

3. Group dynamics-keep the entire group active during the session
Set goals Assign roles Set a time limit Pay attention to the entire group

Janicik & Fletcher, 2003

Ask patients permission Establish rules & goals Set a time limit Assign roles Debrief Feedback (private)

Patients Room
Introduce all Brief overview Diagnose learner Diagnose patient

Ask patient if they have questions Closure

Conduct focused teaching

Discussion
Follow-up with patient

Janicik & Fletcher, 2003

In Summary

Provides an opportunity to:

Gather additional information Directly observe learners skills Role model skills and behaviors

Humanizes care by involving patients Engages trainees in an active learning process Includes patients in the learning process Improves patients understanding

To study the phenomena of disease without books is to sail an uncharted sea. Whilst to study books without patients is not to go to sea at all.

Sir William Osler (1849-1919)