Bedside Teaching

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 patient’s 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 student’s 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 Patient Teacher Learner • Trust • Respect • Transfer of information and emotion

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” • 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 patient’s and learner’s 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

Patient’s Room Ask patient’s permission Establish rules & goals Set a time limit Assign roles Diagnose learner Diagnose patient Introduce all Brief overview Conduct focused teaching Discussion Ask patient if they have questions Closure Debrief Feedback (private) 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)

Bedside Teaching