Bedside clinical teaching for medical students at UNC Peadar G Noone, MD FCCP FRCPI UNC Chapel Hill. AOE UNC Chapel Hill

Background l For generations, clinical bedside teaching was the basis of medical school education (think of the weighed down white coat – hammers, ophthalmoscopes, tuning forks etc) l Started with the clinico-pathologic correlation science in the late 19 th century (the Oslerian school) l UK / Irish medical school teaching (the “colonial” system) still heavily bedside focused l Less so in the US: recent publications lament this decline (though not everyone in agreement).

Outstanding clinical teachers in history: l Cheyne l Graves l Stokes l Corrigan l Adams l Wilde l Osler l Verghese (Stanford)

Noone background: Traditional medical school, 3 basic science years, 3 years of clinical training, heavily bedside focused Intern: small community hospital with very charismatic clinician teacher at the helm Every ward round was a teaching round, every clinical point, sign and laboratory value squeezed dry Post graduate examination in British Isles (MRCPI/MRCP) still involves several bedside components with real patients and patient data 2010: Invited back as extern examiner for the “Final Med” exams at RCSI Dublin

Bare below the elbow, no tie, jewelry

Today: l Abraham Verghese –NEJM article “Culture shock – patient as icon, icon as patient”* l Spoke about the “tension” between traditional approaches (the body as a text) versus the care of the “iPatient” (in the “bunker”) l l Whose fault – us as teachers?  Time, expectations, the encroachment of more exciting technologies, computerized records  Do our students want anything different? * NEJM 2008; 359:

Lets get back to basics at UNC: Inspect Palpate Percuss Auscultate Cerebrate

A pilot study of rotating bedside clinical tutorials for medical students at UNC l Hypothesis: That med students want bedside clinical teaching, and that data will support that l Aims: 1. To study the feasibility of rotating clinical tutorials for clinical students 2. To gather data to assess the benefits of focused teaching in the context of modern medical education

Preliminary data: Feedback over many years of clinical teaching on rounds, enthusiastic generally, perhaps there is indeed a “hunger” for this type of approach There is a literature supporting this from formal studies e.g. NEJM: Images in clinical medicine etc

Objectives: To teach History taking skills Clinical exam Presentation skills Clinical reasoning Professionalism Spin off benefits: Attending learn more about patients problems Patient benefits of learning about their disease

Methods: Advertised via student forums, flyer and direct conversations with students on the wards communication usually with first-come-first- served sign up Once every two to three weeks. Strictly bedside, appropriate patient selection important One to two hours depending. Questionnaire formulated (based on the literature and my instincts)

Results: Anonymous n=11 sessions N=31 students Stretched over several months Data analyzed with help of UNC student on work experience (Melissa House). Data qualitative, showing simple outcomes of various measures the students were asked to score

Conclusions: Generally the tutorials were well received Scored pretty well on most measures Consistent with what is in the popular press and formal medical literature Did not ask for feedback from patients Did not follow up long term

Limitations: Time consuming: Students, teacher time (afternoon formal teaching, MPH, research, organization and communication) Student understanding of the principles (bedside? – you mean in the room all that time?; how are we supposed to do this? Are we just to turn up?) Patient availability and quiet time (its hard to get an hour+ in a room undisturbed) Other (vasovagal episodes in two students not used to spending that much time on their feet in the room)

ACKNOWLEDGEMENTS: The Academy of Educator Grant Mechanism Melissa House work study student UNC Med students The willing patients