Bedside teaching Azim Mirzazadeh MD Azim Mirzazadeh MD Assistant Professor Division of General Internal Medicine Department of Medicine Tehran University of Medical Sciences

Topics Brief overview of: The benefits and challenges of bedside teaching The benefits and challenges of bedside teaching The strategies for improving teaching at the bedside The strategies for improving teaching at the bedside

There should be ‘‘no teaching without the patient for a text, and the best teaching is often that taught by the patient William Osler

Definition In modern times our definition of bedside teaching (BST) includes any teaching done in the presence of the patient, regardless of the setting In modern times our definition of bedside teaching (BST) includes any teaching done in the presence of the patient, regardless of the setting Therefore, it may occur in ambulatory clinic, inpatient ward or conference room Therefore, it may occur in ambulatory clinic, inpatient ward or conference room

Current situation Several surveys indicate that clinical teaching is moving away from the patient’s bedside into conference rooms and hallways (Nair et al, 1997)

Current situation It is dishearting to realize that the time allotted to BST declined from 75% of teaching time 30 years ago to just 16% by 1978 and is certainly much lower now It is dishearting to realize that the time allotted to BST declined from 75% of teaching time 30 years ago to just 16% by 1978 and is certainly much lower now (El-Baghir, 2002) Estimates of time actually spent at the bedside vary from 15% to 25% Estimates of time actually spent at the bedside vary from 15% to 25% (Ramani et al, 2003)

Why the bedside teaching is so important?

Benefits Opportunity to: Opportunity to: Humanizes care by involving patients Humanizes care by involving patients Encourages the use of understandable and non-judgmental language Encourages the use of understandable and non-judgmental language gather additional information from the patient directly observe students’ skills role model skills and attitudes

Benefits (con.) Active learning process in which adults learn best Active learning process in which adults learn best Patients feel activated and part of the learning Patients feel activated and part of the learning Improves patients’ understanding of their disease and the work-up Improves patients’ understanding of their disease and the work-up

What’s the opinion of different participants about BST?

Major participants Bedside Teaching patient Faculty trainees

Faculty 88% of attendings preferred that cases NOT be presented at the patient’s bedside 88% of attendings preferred that cases NOT be presented at the patient’s bedside (Kroenke, et al. 1990) 47% of attending physicans who had practiced less than 10 years favored presenting and teaching away from the bedside 47% of attending physicans who had practiced less than 10 years favored presenting and teaching away from the bedside (Wang-Cheng, et al. 1989)

Faculty Of all respondents (120), 95% agreed or strongly agreed that BST is an effective way to teach professional skills Of all respondents (120), 95% agreed or strongly agreed that BST is an effective way to teach professional skills (Nair, et al. 1998) (Nair, et al. 1998)

Trainees 96% of residents preferred that cases NOT be presented at the patient’s bedside 96% of residents preferred that cases NOT be presented at the patient’s bedside Respondents believed that only 30% of an attending's rounding time should be spent at the bedside Respondents believed that only 30% of an attending's rounding time should be spent at the bedside (Kroenke, et al. 1990) Only 2% of housestaff and 4% of students felt comfortable presenting cases at the bedside Only 2% of housestaff and 4% of students felt comfortable presenting cases at the bedside (Wang-Cheng, et al. 1989)

Trainees 100% of the students, interns and residents (N=136) believed bedside teaching was valuable 100% of the students, interns and residents (N=136) believed bedside teaching was valuable Once they experienced it, over half said they did not receive enough of it Once they experienced it, over half said they did not receive enough of it (Nair, et al. 1997) (Nair, et al. 1997)

Patients 85% of patients preferred to be present when their cases were presented 85% of patients preferred to be present when their cases were presented (Wang-Cheng, et al. 1989) 68% found that it increased their understanding of their medical problems 68% found that it increased their understanding of their medical problems 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 anxious 83% said it did not make them anxious 85% said they do not think that bedside teaching breaches confidentiality 85% said they do not think that bedside teaching breaches confidentiality 84% said they would recommend bedside teaching to other patients 84% said they would recommend bedside teaching to other patients (Nair et al. 1997)

Conclusion We see that physicians have echoed some of our same initial reactions to bedside teaching We see that physicians have echoed some of our same initial reactions to bedside teaching when bedside teaching is actually studied, patients and learners appreciate it and find it effective when bedside teaching is actually studied, patients and learners appreciate it and find it effective

Conclusion It is time we stopped blaming patients and students for our own insecurities at the bedside

Why the bedside teaching is so sparingly used?

Barriers to Bedside Teaching Teacher-related Teacher-related Teaching climate–related Teaching climate–related System-related System-related Patient-related Patient-related Miscellaneous Miscellaneous (Ramani et al. 2003)

Barriers to Bedside Teaching 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 Teaching 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 Teaching Interruptions (phone calls, visitors, pagers) Short patient stays Too much technology System-related

Barriers to Bedside Teaching Patient-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 Teaching

Strategies for improving BST 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)

Model 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 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 Practices Microskills of teaching: Focused Teaching Diagnose the patient Diagnose the learner Targeted teaching Observe Question Role model Practice Teach general concepts Give feedback

Model of Best BST Practices Limit time and goals for the session Include everyone in teaching and feedback Group Dynamics

Take 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 readings Ramani S. “Twelve tips to improve bedside teaching.” Med Teach. 25(2): (provided) Ramani S. “Twelve tips to improve bedside teaching.” Med Teach. 25(2): (provided) Janicik RW, Fletcher KE. “Teaching at the bedside: a new model.” Med Teach (2): Janicik RW, Fletcher KE. “Teaching at the bedside: a new model.” Med Teach (2): Ramani S., et al. “Whither Bedside Teaching? A Focus- group Study of Clinical Teachers. Acad Med (4) Ramani S., et al. “Whither Bedside Teaching? A Focus- group Study of Clinical Teachers. Acad Med (4)

Medicine is learned by the bedside and not in the classroom William Osler

Thank you