Quo Vadis? Bedside Teaching for Students of Medicine

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Quo vadis? Bedside teaching for students of medicine

Dr Ananthakrishnan Raghuram MD MRCPI FRCP PG

“Medicine is learned by the bedside and not in the classroom” “No teaching without a patient for a text, and the best teaching is that taught by the patient himself”

These words by Sir William Osler ring true to this day. My personal perception is that there are a number of educational opportunities available within the medical wards. Educating medical students, therefore, should be best done at the bedside of the patients. While a sound theoretical knowledge is imperative, there can be no substitute for experiential learning. Since the days of Hippocrates, medical teaching has been traditionally an apprenticeship. Latterly, with reduction in training hours, there has been a trend towards directed and didactic teaching often outside the workplace.

Why do it?

The General Medical Council (GMC) is responsible for standards in medical education and has embarked on a process of licensing of doctors. Hospitals have to show evidence that their training programmes are robust and this study and its implementation will help demonstrate this.

At the bedside as against the classroom or lecture theatre, there is an opportunity to utilise most special senses (hearing, vision, smell, touch). There is an immediate interaction between the learner and the teacher with the patient taking an active role in the process. This improves retention and recall and later will provide the events for future “Gestalt” moments! I remember vividly my first patient with foetor hepaticus associated with advanced liver disease; and the “ anchovy sauce “ of the amoebic liver abscess needs to be seen (and smelt) not heard second hand through lectures or online!

Another advantage of having the patient in the room is that it allows the students to genuinely interrogate the history, analyse it and interpret them in the light of basic patho-physiological knowledge. It also allows the students to learn how to avoid red herrings in history taking and disappearing down several cul de sacs offered by helpful patients eager to place all possible information at the students’ door.

Bedside teaching is very well suited for demonstration and the teacher acts as a personal exemplar in the

interaction with the patient. What better way to demonstrate empathy and recognition of the patient’s autonomy?

Demonstration of physical signs- not only to make the correct findings but also learning the appropriate way to elicit signs is best learnt with the patient. Increasingly there are simulations which can be used to teach examination as well as practical skills. While these are very useful in their own right, the lack of a “real” patient means that the “softer” interpersonal skills cannot be taught and I believe that these are just as important as getting the right diagnosis.

How to do it?

Before the teaching Teachers should identify the learning needs of the students and have a clear idea of what learning will take place. If necessary the teachers revise their own skills in examination. The patient(s) have to be identified and necessary permissions obtained. The patients need to be briefed as to what to expect during the teaching session. It will be very useful to examine the patient first and confirm points in history and examination. Planning is the key to minimise last minute distractions.

During the teaching The number of students around a patient should be limited both for patient comfort as well as to enhance the educational opportunities. The teacher may either demonstrate findings or observe the students performing the same. Although gentle nudges if the students are veering off course may be necessary, it is often useful to observe silently and give the feedback later. This gives the student confidence to acquire experience.

Family members may ask to be present and may often, particularly in the elderly, provide additional information in the history.

Discussion about findings, their interpretation and management plans are best done outside the immediate patient area. If, however, this is done at the bedside, the patients need to be warned that some of the discussions may not pertain to them. Students can then ask questions or seek clarifications and identify further learning needs. Teachers must avoid humiliation and undermining of students as this is detrimental to the learning environment.

After the event It is important to assess whether the learning needs were met and an evaluation of the learning process happens. Both trainees and trainers can then plan for the next educational opportunity. Feedback is critical, both for the student and for the trainer- referred to as “reflection in action”. (Schon) It is important to bring past experiences to act as “an exemplar for the unfamiliar one”. (Thomas Kuhn).

So, why doesn’t this happen routinely?

The major challenge is in changing attitudes. In a study looking at bedside teaching for junior doctors, Janicik and Fletcher, identified barriers to bedside teaching which included a misconception that patients might be upset; house staff being tired and unmotivated and the teacher’s lack of confidence in their own bedside teaching skills.

If medical education is being conducted on the wards with acutely ill patients, there is an inevitable conflict between patient care and trainee education. Although concerns may be raised about patient perception of teaching ward rounds, evidence from the literature suggests that this is unfounded (Lehmann). Medical jargon could be avoided in the presence of the patients and explanations are kept simple. Informed consent will need to be obtained from patients before the teaching and patients assured that their medical care would not be adversely affected should they choose not to take part.