Challenges and Opportunities with Bedside Teaching

4-6 Minutes

Author: Julpohng Vilai, MD

Purpose

To provide clinical educators with an understanding of how bedside teaching has evolved and describe its importance in modern medical education.

Learning Objectives

1. Describe the historical significance of bedside teaching in medical education;

2. Discuss two challenges with bedside teaching in current medical practice; and

3. List three skill sets that are idealy taught at the bedside.

Sir William Osler is often quoted as saying: “medicine is learned by the bedside and not in the classroom.”(1) Several authors have lamented the decline in the physician’s clinical skills in recent years, and many cite a decrease in bedside rounds and teaching as an important factor in the perceived decline in clinical skills.(2,3) Whereas clinical education of medical students in the late 1900s took place at the bedside for as much as 75% of the time, it is now estimated to occur less than 20% of the time.(4)

Current Challenges with Bedside Teaching

Despite its purported utility in clinical education, many factors have led to a decline in bedside teaching over the past decades. First, advances in technology have created educational environments in which real patient interaction may be replaced by medical simulation to various degrees.(5) Additionally, many hospital workflows necessitate more time spent on computers and navigating electronic health records as well as increasing demands on a clinician’s time.(6) Furthermore, the focus of health systems on cost effectiveness, shorter length of stay, and higher caseloads reduces the time available for bedside teaching.(7)

Colleges and universities have increasingly placed greater value on income-generating activities such as research and billable patient care over teaching.(6) While top tier researchers and cutting-edge physicians are celebrated, teaching can be seen as a burden borne largely by those of lower academic rank; clinical faculty are often not afforded protected teaching time and are overburdened with clinical responsibilities.(6)

Patient discomfort, privacy, and disease transmission are sometimes cited as reasons to preferentially use more theoretical models such as a lecture hall, conference room, or simulation.(8)

Bedside Teaching and Essential Skills for Medical Practice

Given the above barriers, why should we still look to bedside teaching as a valuable strategy? There are a number of reasons to not abandon ship for a shinier boat. Bedside teaching is widely considered an ideal modality to teach many essential clinical practice skills such as history taking, physical examination, and professionalism can be demonstrated and learned.(9) However, the dramatic advances in diagnostic testing and imaging, has led to reliance on these technologies at the expense of clinical skills.(9) Still, medical students and residents have been shown to be more motivated to participate in problem-solving and clinical reasoning if their preceptor acts as a role model to provide appropriate guidance and demonstration.(10,11)

Evidence suggests that in at least 70% of cases, a comprehensive history and physical examination alone yields an accurate diagnosis.(12)

Several other critical skills can best be taught at the bedside, include learning to effectively communicate with real patients, exposure to ethical considerations such as navigating patient confidentiality, and adequately obtaining a structured history without medical jargon.(10)

In cases where the assertion is that patient privacy and experience should trump bedside teaching, there is a significant body of evidence suggesting the contrary: patients and families correlate bedside rounding with better and more compassionate care.(13)

Furthermore, in the face of declining clinical skills, an overburdened physician workforce without adequate time to train future generations may lead to poorer outcomes.(7) Data from U.S. hospitalists suggested that capping the patient census improved resident job satisfaction, and higher workloads led to deleterious consequences such as delays in diagnosis, communication errors, and more complications.(7)

Considerations from your Education

Medicine has changed dramatically since the days of Sir William Osler. Yet, interactions with real patients, particularly when modeled by experienced, effective, and compassionate physicians, continues to have an important place in medical education. Consider our own medical training: 

• What are some memorable teaching moments on rounds or at the bedside? 

• Who were the attendings or mentors who were “excellent teachers” and what did they do that made such an impression on you?

• Do you still remember some concepts or diseases because of the way it was presented, annotated, or demonstrated by someone? 

• What methods, modalities, and strategies were employed that you either found helpful or were ineffective? 

Thinking about these questions can help us recognize successful teaching approaches that we, in turn, can use and model for future generations of clinicians. We will cover additional techniques and methods for clinical teaching in a future edition of Preceptor including the One-Minute Preceptor method.■

References

(1) Stone MJ. The wisdom of Sir William Osler. Am J Cardiol. 1995;75:269-76.

(2) Peters M, Ten Cate O. Bedside teaching in medical education: A literature review. Perspect Med Educ. 2014;3:76-88.

(3) Hazan A, Haber J. Break the cycle and prioritize bedside teaching. Emerg Med News. 2017;2:17.

(4) Crumlish CM, Yialamas MA, McMahon GT. Quantification of bedside teaching by an academic hospitalist group. J Hosp Med. 2009;4:304-7.

(5) Bogossian F, Cant R, Ballard E, Cooper S, Levett-Jones T, McKenna L, Ng L, Seaton P. Locating “gold standard” evidence for simulation as a substitute for clinical practice in prelicensure health professional education: A systematic review. J Clin Nurs. 2019;28:3759-75.

(6) Faustinella F, Jacobs RJ. The decline of clinical skills: A challenge for medical schools. Int J Med Educ. 2018;9:195-7.

(7) Rousseau M, Konings K, Touchie C. Overcoming the barriers of teaching physical examination at the bedside: More than just curriculum design. BMC Med Educ. 2018;18:302.

(8) Nair B, Coughlan J, Hensley M. Impediments to bed-side teaching. Med Educ. 1998:32:159-62.

(9) Verghese A, Brady E, Kapur C, Horowitz R. The bedside evaluation: ritual and reason. Ann Intern Med. 2011;155:550-3.

(10) LaCombe MA. On bedside teaching. Ann Intern Med. 1997;126:217-20.

(11) Kroenke K, Omori D, Landry F, Lucey C. Beside teaching. South Med J. 1997;90:1069-74.

(12) Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. Am Heart J. 1980;100:928-31.

(13) Thibault G. Bedside rounds revisited. N Engl J Med. 1997:336:1174-5.