1. A CASE FOR BEDSIDE TEACHING
Prof . B. K. Nair
Ms. J. Coughlan
Prof. M J. Hensley

2. What is it? Patients like it Students like it Students need it
Students want more of it
Teachers like it and can not do it
What should we do about it?

3. This talk Why revisit these papers
Learner, patient and teacher perspective
Should we improve and increase BST
Where from here?

4. “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.”
(Osler )

5. Medical Education
Promote acquisition of life long active learning habits
Introduce PBL
Shift from lectures to small group and independent learning
(World Conference on Medical Education Edinburgh 1988)

6. “Bedside teaching should be integrated in the teacher-student and patient-student relationship”
(WHO - Brussels 1992)

7. What is bedside teaching?
Any where where there is a patient
Ambulatory clinic
Operating theatre
Home
Wards

8. Advantages Additional info Observe student skills Role modeling
Humanize care
Active learning
Activated patient
Improved understanding of patient

9. Challenges for educators
56% diagnoses from history
80% from history and physical
Learners distracted by technology
Teachers are overwhelmed by service and administration
What should we do?

10. What happened ?
75% of time in 1960s
16% in 1978
Less in 2005?

11. Most common ‘barriers’
Patient discomfort
Lack of confidentiality
Hard to locate
Learners reluctant
Time consuming
Teacher uncomfortable

12. LEARNER

13. AIM
To investigate impressions and opinions about bedside teaching among
students, interns and residents
patients.
We wanted to know what these people think about bedside teaching.
Was it effective,
did they get enough?
Did they like it?

14. STUDY DESIGN Student Survey (handed out /mailed out)
Intern & Resident Survey (Mailed out)
Patient Survey (administered)
Students:
distributed at lectures and handed back at the end of the lecture. Time (about 10 minutes) was set aside for students to complete it. Attended 3 lectures.
Mailed to country students (x 2).
Interns and Residents:
Mailed to home address - reminder sent after one month.
Patient Survey:
Verbally administered by researcher.
Kichu will explain later about how patients were recruited for the study.

15. STUDY DESIGN Yr 5 Students Interns Residents
Group: Response Experience:
Yr 5 Students
Interns
Residents
Up to Yr 4
Up to Yr 5
It was anticipated that S I and R responses would be coloured by three distinctly different experiences:
Year 5 students responses by their experiences up to the end of Year 4...
Interns by their expiences up to the completion of the Bachelor of Medicine course but without the influence of post-graduate work experience ...
and Residentsresponses with the benefit of one years clinical experience.
NB - ONLY ASKED ABOUT B.MED BST EXPERIENCES.
1 year post grad

16. SURVEY DESIGN: Student, Intern and Resident Survey
Self administered questionnaires:
Age
sex
status
Best location for Case Presentations
SIR surveys DID NOT DIFFER with respect to
AGE
SEX
STATUS
BEST LOCATION FOR CASE PRESENTATION.
- bedside
- hospital corridors
- conference / tutorial room
- combination bedisde and conference room
- other (please state)
ANY COMMENTS?

17. SURVEY DESIGN Student, Intern and Resident Survey
Is BST an effective way to teach?
Did you get enough BST?
professional skills generally?
specific professional skills?
Do you think BST is a valuable way to gain Professional Skills (Y/N)
Do you think you got enough BST during the Bachelor of Medicine? (so far).
WE WANTED A CLEARER PICTURE - TO REFINE OUR UNDERSTANDING OF STUDENT PERCEPTIONS OF BST AS A METHOD TO IMPART PROFESSIONAL SKILLS.
Specific Professional Skills used a five-point Likert scale
Strongly Agree - Strongly Disagree)
Do you agree that BST is an effective way to develop these skills?
Did you receive enough bedisde teaching in that particular skill? (Y/N)

18. SPECIFIC PROFESSIONAL SKILLS
Communication Skills
Obtaining Medical Histories
Conducting Physical Examinations
Applying Basic Science Knowledge
Record Keeping
Evidence-based Medicine
Self-Directed Learning
Time Management
WHY DID WE CHOOSE THESE SKILLS?:
Anderson et al (1991) in “Comparing Students’ Feedback about Clinical Instruction with Their Performance” Academic Medicine 66;1:29-34 used first four in students self-reporting skill development. Whilst we were not after the same results this study showed a strong link between students reports about quality of clinical teaching and their self reported and actual performance in OSCEs.
The first four of these skills plus self directed learning are traditional core activities within the B.Med curriculum.
Record Keeping and Time Management have not been explicity recognised as core skills.
Emerging as an important skills is evidence based medicine which is currently developing a foothold as a legitimate and necessary skill for the safe and efficacious practice of medicine (hence its inclusion in this study).

19. TARGET POPULATION 200 Student Intern Resident Total
Male 13% 11% 12% 35.5%
Female 26% 18% 21% 64.5%
Total 39% 29% 32% 100%
NB: Male residents only represent 12% of target population.
Females represent 64.5% of target population.
200

20. RESPONSE RATES (%) 136 (68) WHO RESPONDED:
Student Intern Resident Total
Male 10% 12% 5% 27%
Female 29% 23% 22% 73%
Total 38% 35% 27% 100%
136
(68)

21. SITE PREFERENCES: RESULTS:
THIS SLIDE REPRESENTS ACTUAL NUMBERS OF INDIVIDUALS WHO RESPONDED:
Bedside - 3%
Hospital corridor 2%
Conference / tut room 53%
Combination bed / tut room 41%
Other 1%

22. GENERAL PROFESSIONAL SKILLS%
THIS SLIDE CLEARLY DEMONSTRATES THAT S,I & R all think that BST is a valuable way to develop professional skills
I should note here that the n at the base of the slide indicates the number of respondents rather than the number of S, I or R.
Confidence intervales for each of these show no difference between SIR for either Effective nor Enough.
S I R S I R
n=51 n=48 n=37
n=37 n=17 n=22

23. COMMUNICATION SKILLS % n=43 n=44 n=35 n=38 n=40 n=30 S I R S I R
Overall % 79%
n=43 n=44 n= n=38 n=40 n=30

24. PHYSICAL EXAMINATION % n=51 n=48 n=36 n=18 n=26 n=29 S I R S I R
Overall % 47%
n=51 n=48 n= n=18 n=26 n=29

25. BASIC SCIENCE % n=42 n=40 n=28 n=12 n=17 n=14 S I R S I R
Overall % %
n=42 n=40 n= n=12 n=17 n=14

26. SELF DIRECTED LEARNING%
S I R S I R
Overall % %
n=37 n=26 n= n=27 n=25 n=25

27. RECORD KEEPING % n=24 n=29 n=22 n=10 n=7 n=11 S I R S I R
N.B. only 54% overall 21%
n=24 n=29 n= n=10 n=7 n=11

28. EVIDENCE-BASED MEDICINE%
S I R S I R
overall % %
n=32 n=31 n= n=14 n=13 n=15

29. PATIENT

30. SURVEY DESIGN Patient Survey
Number of days in hospital.
Experienced BST? No. of times?
understand your illness
enjoy it
feel anxious
inappropriate discussion
forewarning
breach of confidentiality
recommend to other patients

31. PATIENT CRITERIA competent in written and spoken English
not cognitively impaired
not too ill
voluntary informed consent

32. Results: (subjects) Interviewed Had BST n= 160 n=100 (63%)
Average Age yrs yrs
% Males
% Females
Average Stay days days
Frequency of BST 1 per 2.4 days

33. Patient Responses Understanding 68 32 0 Enjoy BST 77 17 6
% % %
Yes No No Resp
Understanding
Enjoy BST
Anxious
Inappropriate discussion
Forewarning
Breach of confidentiality
Recommend to other patients

34. TEACHER Students love it and do not get enough?
Patients like it and gain from it
Why not do it then?

35. AIM
To investigate impressions and opinions about bedside teaching among clinical teachers
BST Definition:
All patient related teaching including inpatients, outpatients, theatre & rooms.
We wanted to know what these people think about bedside teaching.
Was it effective,
did they get enough?
Did they like it?

36. STUDY DESIGN Self Administered questionnaire:
coded to identify non-responders
follow up mail out after 6 weeks
data entered and analysed anonymously
Students:
distributed at lectures and handed back at the end of the lecture. Time (about 10 minutes) was set aside for students to complete it. Attended 3 lectures.
Mailed to country students (x 2).
Internsand Residents:
Mailed to home address - reminder sent after one month.
Patient Survey:
Verbally administered by researcher.
Kichu will explain later about how patients were recruited for the study.

37. SURVEY DESIGN: Three sections: 1 Respondent details
(time practicing medicine, specialty)
2 Opinions about BST
(general and specific professional skills)
3 Hindrances to BST
SIR surveys DID NOT DIFFER with respect to
AGE
SEX
STATUS
BEST LOCATION FOR CASE PRESENTATION.
- bedside
- hospital corridors
- conference / tutorial room
- combination bedisde and conference room
- other (please state)
ANY COMMENTS?

38. SPECIFIC PROFESSIONAL SKILLS
Communication Skills
Obtaining Medical Histories
Conducting Physical Examinations
Applying Basic Science Knowledge
Record Keeping
Evidence-based Medicine
Self-Directed Learning
Time Management
WHY DID WE CHOOSE THESE SKILLS?:
Anderson et al (1991) in “Comparing Students’ Feedback about Clinical Instruction with Their Performance” Academic Medicine 66;1:29-34 used first four in students self-reporting skill development. Whilst we were not after the same results this study showed a strong link between students reports about quality of clinical teaching and their self reported and actual performance in OSCEs.
The first four of these skills plus self directed learning are traditional core activities within the B.Med curriculum.
Record Keeping and Time Management have not been explicity recognised as core skills.
Emerging as an important skills is evidence based medicine which is currently developing a foothold as a legitimate and necessary skill for the safe and efficacious practice of medicine (hence its inclusion in this study).

39. Response Rate
Survey Recipients 152
Respondents 120
Response Rate 79%

40. Respondents Student Intern Resident Total Male 13% 11% 12% 35.5%
Female 26% 18% 21% 64.5%
Total 39% 29% 32% 100%
NB: Male residents only represent 12% of target population.
Females represent 64.5% of target population.

41. Case Presentation Site Preferences%

42. Lack of Support %
Overall % %

43. Noisy Ward %
Overall % %

44. Own Understanding %
Overall % %

45. Patient Anxiety %
Overall % %

46. Patients not in bed %
Overall % %

47. Student Basic Science %
Overall % %

48. Student Clinical Skills%
Overall % %

49. Time Constraints %
Overall % %

50. Average Hindrance Scores

51. Other Hindrances Group size over 4 or 5
Limited patients with good clinical signs
“Good” patients become exhausted
Shorter length of stay
Reduced bed numbers
Emphasis on community care

52. Other Hindrances (2) More work demands Low recognition of the role
Outpatients not structured for BST
Student availability
Lack of privacy in crowded ward

53. Other Hindrances (3) Interruptions from acute clinical problems
Interruptions from bedside telephones
Interruptions from visitors
Lack of warning to patients on admission

54. Comparison of % of Students and Teachers who agreed or strongly agreed that BST is an effective way to develop specific professional skills. %

55. Ideal model Ask ahead of time Introduce the team
Brief overview and explain
Avoid technical jargon
Base teaching on the data on patient
Genuine closure
Return visit by a member to clarify

56. Ideal model Focused teaching Diagnose patient Diagnose learner
Targeted teaching
Role modeling
Feed back

57. Ideal model Group dynamics Limit time and goals for the session
Include everyone in teaching and feedback

58. Advantages of bed side teaching
Patient found it therapeutic
Humanize medicine
“Gomers/ social admissions” and “acopia” are people too

59. Conclusions Patients like it Students like it Students need it
Teachers like it and can not do it
What should we do about it?

60. “The facts are locked up in the patient - to the patient, therefore, he must go”
Abraham Flexner, 1910

61. Bedside teaching Where from here? How do we engage clinicians?
This is our core business!
Should do more qualitative reserach

62. HISTORY TAKING % n=45 n=47 n=35 n=35 n=34 n=30 S I R S I R
Overall % 72%
n=45 n=47 n= n=35 n=34 n=30

63. Effectiveness and quantity of BST in Medical History Taking. (%)

64. Effectiveness and quantity of BST in the application of basic science knowledge. (%)

65. BST is an effective way to teach professional skills:%
THIS SLIDE CLEARLY DEMONSTRATES THAT S,I & R all think that BST is a valuable way to develop professional skills
I should note here that the n at the base of the slide indicates the number of respondents rather than the number of S, I or R.
Confidence intervales for each of these show no difference between SIR for either Effective nor Enough.
S I R S I R

66. Effectiveness and quantity of BST in Record Keeping. (%)

67. Effectiveness and quantity of BST in Evidence-based Medicine. (%)

68. Effectiveness and quantity of BST in Self Directed Learning (%)

69. Role modelling is an important part of BST%
S I R S I R
Overall % 47%

70. BASIC SCIENCE %
S I R S I R
Overall % %

71. EVIDENCE-BASED MEDICINE%
S I R S I R
overall % %

72. HISTORY TAKING %
S I R S I R
Overall % %

73. PHYSICAL EXAM %
Overall % %

74. RECORD KEEPING %
Overall % %

75. Self Directed Learning%
Overall % %

76. Time Management %
Overall % %

77. BST makes patients anxious%
S I R S I R
Overall % 79%

78. Patients like to be a part of BST%
S I R S I R
Overall % 72%

79. COMMUNICATION % S I R S I R 14 14 16 11 10 15
N.B. only 54% overall 21%