Transcript Bedside teaching
Bedside teaching
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 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 1849-1919
Definition
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
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
(El-Baghir, 2002)
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: • gather additional information from the patient • directly observe students’ skills • role model skills and attitudes Humanizes care by involving patients Encourages the use of understandable and non-judgmental language
Benefits (con.)
Active learning process in which adults learn best Patients feel activated and part of the learning Improves patients ’ understanding of their disease and the work-up
What’s the opinion of different participants about BST?
Major participants
Faculty trainees Bedside Teaching patient
Faculty
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
(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
(Nair, et al. 1998)
Trainees
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
(Kroenke, et al. 1990)
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
Once they experienced it, over half said they did not receive enough of it
(Nair, et al. 1997)
Patients
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 77% said they enjoyed it (only 17% did not) 83% said it did not make them anxious 85% said they do not think that bedside teaching breaches confidentiality 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
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
Teaching climate–related
System-related
Patient-related
Miscellaneous
(Ramani et al. 2003)
Barriers to Bedside Teaching
Teacher-related
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
Barriers to Bedside Teaching
Teaching climate–related
Time constraints
Lack of faculty training in bedside skills
Lack of rewards for teaching
Lack of teaching role models in faculty’s own training
Barriers to Bedside Teaching
System-related
Interruptions (phone calls, visitors, pagers)
Short patient stays
Too much technology
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
Barriers to Bedside Teaching
Miscellaneous
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
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
Attend to Patient’s Comfort
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
Model of Best BST Practices
Focused Teaching
Microskills of teaching: Diagnose the patient Diagnose the learner
Observe Question
Targeted teaching
Role model Practice Teach general concepts Give feedback
Model of Best BST Practices
Group Dynamics
Limit time and goals for the session
Include everyone in teaching and feedback
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.” 2003. Med Teach. 25(2): 112-115. (provided)
Janicik RW, Fletcher KE. “Teaching at the bedside: a new model.” Med Teach. 2003. 25(2): 127-130.
Ramani S., et al. “Whither Bedside Teaching? A Focus-group Study of Clinical Teachers. Acad Med. 2 0 0 3. 78 (4)
Medicine is learned by the bedside and not in the classroom
William Osler 1849-1919