A PRIMER ON BEDSIDE TEACHING

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A PRIMER ON BEDSIDE TEACHING

• Dr. Brendan MacDougall
• Professor
• Section of GIM
• University of Manitoba
• Rocky Mountain GIM Meeting November 2008

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• For the junior student in medicine and surgery
  it is a safe rule to have no teaching without a
  patient for a text and the best teaching is that
  taught by the patient himself
• Sir William Osler
• Address to the New York Academy of Medicine,
  1903

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Advantages of Bedside Teaching

• Verification of the History and Physical
  presented (case review versus actual teaching)
• Ability to role model
• a) humanistic behavior
• b) professionalism
• c) clinical expertise/reasoning
• d) time management
• Observation of both the team and individual
• Ability to teach history and physical exam
  techniques

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Role Modeling may be the most important reason

• Students Observe
• Process
• Store experience
• Modify it
• Practice it
• Refine it
• Model for others

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TEACHERS

• Low incentive to provide teaching competing
  responsibilities
• Attenders have forgotten certain physical
  examination techniques
• Deficient institutional expectation/incentives/rec
  ognition for learning
• Insufficient time to provide effective feedback

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How to Improve Attenders Bedside Teaching

• Develop a faculty evaluation system with regular
  feedback.
• Having a department that recognizes teaching
  excellence.
• Peer evaluation of bedside teaching using set
  criteria.
• Videotape teaching for self evaluation and peer
  review.
• Provide an educational consultation to poor
  teachers.

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Obstacles to Bedside Teaching

• Not enough time.
• Patients often a) too sick/confused
• b) uncooperative
• c) absent
• Short length of stay or patient still in the ER.
• Privacy issues.
• Too many interruptions.
• Too many other health professional on rounds with
  the team.

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Obstacles to Bedside Teaching

• Fear of embarrassment, loss of autonomy and
• compromised relationship with patients
• Learner fatigue
• Different training levels of learners
• Poor group dynamics
• Low expectations for teaching

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Some Strategies to Employ to Overcome (some of)
These Obstacles

• Set an educational contract with each group on
  day 1
• Prepare the session (realizing spontaneous
  teaching opportunities occur commonly)
• Prepare the patient
• If 1 hour is allotted for teaching, aim for 50
  at the bedside

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Some Strategies to Employ to Overcome (some of)
These Obstacles

• Discuss your objectives and plans before entering
  the room
• Reflect on experience with house staff and with
  yourself
• Review what has been learned
• Make it evidence based
• Provide individual feedback and emphasize the
  positives
• Be enthusiastic infuse the environment with
  energy

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• As with most successful educational
  exercises, PREPARATION is the key.

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Specific Suggestions

• Demonstrate History Physical techniques
  yourself as well as observing individual house
  staff.
• Stand back and have more senior residents act as
  teacher (but prepare them for this)
• Observe the whole group take the history
• Discuss patient
• - function/supports
• - literacy issues
• - psycho-social impact of disease
• - how to use interpreters
• - patient safety issues
• - communication with spouse/family members.
• contd

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Specific Suggestions

• Observe one of the housestaff discussing the
• diagnosis, tests to be done, and/or results
  of tests.
• Teaching how to give bad news
• or
• DNR status better done with one house staff or
• as a simulated exercise
• Provide leadership, direct the learning and
  delegate responsibilities
• Discuss process of reasoning

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At the end of a bedside teaching session ask
yourself the following questions

• Did I
• Prepare the patients and housestaff.
• Make the learning relevant for each housestaff.
• Demonstrate clinical reasoning, professionalism.
• Stimulate self-directed learning.
• Explicitly present the objectives/goals for the
  teaching session.
• Deal with the different learning needs of the
  students and residents.
• Summarize what was accomplished.
• Give the student/resident specific, constructive
  feedback.