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• Your big teaching commitments are attending/teaching rounds but
consider making your own small commitments. Examples:
Teach about one patient per day
Ask one higher level (reasoning) question per patient
Give one teaching pearl per patient on rounds
Prepare 5–8 short teaching scripts (see above) and try to teach
each one once per rotation
Teach one physical exam skill per day.
• Role model what you expect of your learners.
Most teaching happens when the teacher is not trying because teachers are incredibly influential role models for their learners. Many
clinicians easily recall their best professors as inspiring role models
and exceptional caregivers. They often provided valuable insights into
the care of patients just by observing them interacting with their
patients. Learning in the inpatient setting is a powerful experience and
the attitude with which the physician teacher approaches each day and
each patient can set the standard for their team.
References
1. Knowles, MS, Holton EF III, an RA. Swanson. (1998) The Adult
Learner. Gulf Publishing, Houston.
2. Kaufman DM. (2003) ABC of learning and teaching in medicine:
Applying educational theory in practice. BMJ 326: 213–216.
3. William O. (2003) The hospital as a college, in Aequanimitas, 315. In:
Silverman M, (ed), The Quotable Osler. American College of
Physicians Pr, Philadelphia.
4. Irby DM, Wilkerson L. (2008) Teaching when time is limited. BMJ
336(7640): 384–7.
5. Kolb D, Fry R. (1975) Towards an applied theory of experiential
learning. In: Cooper C, (ed), Theories of Group Processes. J Wiley;
London, pp. 33–58.
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L. Coplit
6. Ende J, ed. (2010). Theory and Practice of Teaching Medicine. ACP
Pr, Philadelphia.
7. Skeff KM, Stratos GA, eds. (2010) Methods for Teaching Medicine.
ACP Pr, Philadelphia.
8. Wimmers P, Schmidt H and Splinter T. (2006) Influence of clerkship
experiences on clinical competence. Med Educ 40: 450–8.
9. Wiese, J, ed. (2010) Teaching in the Hospital. ACP Pr, Philadelphia.
10. The Stanford Faculty Development Program in Clinical Teaching
Skills, Stanford University, Leland, 1998.
11. Kroenke K. (1992) Attending rounds. J Gen Int Med 7: 68–75.
12. Bowen JL. (2006) Educational strategies to promote clinical diagnostic reasoning. NEJM 355(21): 2217–2225.
13. Weinholtz, D and Edwards, J. (1992) Teaching During Rounds: A
Handbook for Attending Physicians and Residents. The Johns
Hopkins University Press; Baltimore.
14. Detsky AS. (2009) The art of pimping. JAMA 301(13): 1379–1381.
15. Neher JO, Gordon CC, Meyer B and Stevens N. (1992) A five-step
“microskills” model of clinical teaching. J Am Board Family Pract
5(4): 419–424.
16. Aagaard E, Teherani A and Irby D. (2004) Effectiveness of the oneminute preceptor model for diagnosing the patient and the learner:
Proof of concept. Acad Med 79: 42–9.
17. Furney SL, Orsini AN, Orsetti KE, et al. (2001) Teaching the one-
minute preceptor. A randomized controlled trial. J Gen Intern Med
16(9): 620–4.
18. Ende J. (1983) Feedback in clinical medical education. JAMA 250:
777–81.
19. Hewson M, Little M. (1998) Giving feedback in medical education:
Verification of recommended techniques. J Gen Intern Med 13: 111–6.
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Teaching Tips and Pearls
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Teaching at the Bedside
Somnath Mookherjee* and Brad A. Sharpe
Key Pearls
• Bedside teaching can be a highly valuable educational experience
and is generally well received by patients, learners and teachers.
• Before the bedside teaching session, the teacher should determine
the two to three specific teaching goals for the session.
• Before starting, the teacher should explain the goals and structure
of the encounter to the learners and patient.
• To stay patient-centered and maximize efficiency, the teacher should
ask the patient to try to maintain a list of questions, and if necessary,
return after the teaching encounter to address all issues completely.
• After the session, the teacher should provide direct feedback by
listing one behavior that the learner did well and should continue and one behavior that the learner should modify or not
continue.
Introduction
Bedside teaching is one of the most challenging skills for the teaching
hospitalist. Yet, teaching at the bedside is essential to transform learners
into outstanding clinicians.
1
Moreover, as all bedside teaching occurs in
a clinical context, it is uniquely suited for the teaching of several core
competencies in hospital medicine. First, the learner can benefit from
177
17
Chapter
*University of California, San Francisco, CA, USA.
real world demonstrations of professionalism, including optimal communication strategies with patients, family and nurses. Second, key aspects
of the physical examination can be demonstrated and interpreted in the
context of clinical decisions. Third, patient safety may be emphasized at
the bedside. For example, teachers may point out the presence or absence
of foley catheters or sequential compression devices.
Published literature suggests that bedside teaching is well received by
all involved. Patients tend to value bedside oral case presentations, and
there is no evidence that they object to having their care discussed in their
presence.
2,3
Learners find the bedside useful in learning many competencies and their appreciation tends to be greater the more they are exposed
to bedside teaching.
4,5
Finally, teachers who use this technique feel that it
is effective and rewarding.
6
Despite these benefits, bedside teaching is underutilized.5Barriers
include the perception that bedside teaching is inefficient; fear that the
patient will feel objectified in front of an audience of learners; and learner
discomfort in “performing” in front of a group.
7
In this chapter, we present a simple framework to overcome these barriers and to optimize teaching at the bedside. This framework can be modified and applied to the
multiple forms of bedside interactions, including bedside oral case presentations by students or housestaff, “on the fly” interactions with the
patient and learner, and dedicated teaching visits to the bedside. In addition, we list common pitfalls in bedside teaching and offer strategies to
overcome them (Table 1).
Framework
Set the Stage with Learners — What to Do Before Entering the Room
For bedside teaching to be successful, the teacher must be prepared and
set the stage before entering the room. The teacher should have a general
strategy ahead of time and fine-tune the specific plan in collaboration with
the learners.
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S. Mookherjee and B. Sharpe
1.
Establish your goals ahead of time
Pre-determine the teaching goals for specific patients (e.g. demonstration
of the physical examination for ascites in a patient with cirrhosis, modeling of patient-centered communication in a patient with end-stage
metastatic cancer).
2.
State your established goals clearly to the group
Entering a patients room without all providers having the same plan can be
inefficient and confusing — it is useful to pre-label the bedside encounter
as both a teaching and patient care-related activity. Pause outside the room
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Teaching at the Bedside
Table 1. Common Pitfalls in Bedside Teaching
Pitfall Strategies to Avoid or Overcome
Patient is made to feel that Orient the patient and ask permission for bedside
their care is secondary teaching. Clarify that while there is an educational
to educational priorities. component on a teaching service, the patient’s care
is paramount. Thank the patient for his or her
contribution to medical education.
Patient asks you questions Allow the learner to be at the forefront by taking a
(instead of the learner). step back from the group. Look to the learner
when questions are raised. Maintain patient
centeredness by summarizing and agreeing or
modifying the learner’s responses.
Patient has multiple questions, Ask the session leader not to invite the patient to
encounter takes longer interrupt with questions or clarifications. Rather,
than planned. encourage the patient to write down questions so
they can all be addressed at the same time. Assure
the patient that all questions will be addressed at
the conclusion of the encounter.
You are uncertain if your Describe your findings as accurately as possible. If
physical examination you are not sure how to interpret what you are
finding is “correct.” seeing, share that with the team. By expressing a
plan for how you intend to improve that particular
skill, you will be demonstrating practice-based
learning, a key competency for trainees.
and clearly state the goals: “I am going to demonstrate how to examine
patients for the presence of ascites and I want everyone to practice the techniques as well.”
3.
Define roles and responsibilities
Identify who is to make introductions and lead the conversation with the
patient. If the encounter is to be a bedside presentation, it may be appropriate to have the presenter practice what they will say to the patient to
orient them to the plan (see Explain the goals and structure of the
encounter below).
4.
Establish that there will be debriefing and feedback after the encounter
Constructive feedback is best accepted if the process is normalized and
expected. Clearly state you will be providing feedback when you come
out of the room. For example, consider stating the following, “After you
summarize the plan for the patient, we’ll come out of the room and I’ll
give you feedback on how I think you did.”
Orient the Patient — What to Do When you Enter the Room
1.
Introductions
The designated team member taking the lead should introduce the patient
to the group and then have each person introduce himself or herself; this
should include names, level of training, and role in the patient’s care.
2.
Explain the goals and structure of the encounter to the patient
This is especially important if a bedside oral case presentation is planned.
If unstructured, these encounters may take longer than planned and bias
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S. Mookherjee and B. Sharpe
learners against future bedside presentations. For example, “I am going to
formally present your case to my attending and the rest of the team. We
will do a brief exam and then summarize our plan. It will be more efficient
if you can write down your questions as they come up, so we can address
everything when we wrap up. Is this plan OK with you?”
3.
Elicit any additional goals from the patient
This is important to maintain the patient-centered tone of the interaction.
All additional goals raised by the patient should be addressed. However,
due to time constraints, sometimes it is more appropriate for the attending
to take the responsibility of returning later.
Key Principles to Follow at the Bedside
1.
Follow your pre-arranged structure
Allow the designated learner to lead the conversation. The conversation is
unlikely to be exactly the same as you envision, but rather than interrupting and re-directing (unless absolutely necessary), formulate how to convey your observations as feedback to the learner after the encounter. If the
goal of the encounter is a bedside presentation, avoid interruptions to ask
questions by taking notes; many questions will be answered simply by
waiting. Any additional questions can be asked at the conclusion of the
presentation.
2.
Maintain patient respect
Ask patient for permission before involving learners in interactions
with the patient or in discussing the patient’s case. For example, state
to the patient, “Is it OK if I show the rest of the group some physical
examination findings?” or “We like to think about medical problems
by making a list of possible diagnoses — is it OK if we do that right
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Teaching at the Bedside
now?” Avoid the use of medical jargon and be sure to define terms if
necessary.
3.
Maintain learner respect
Involve all learners and defer to the designated leader whenever possible.
Debrief — Outside the Room
1.
Provide learner-specific feedback
Elicit the designated leader’s self-evaluation of their performance by asking, “How did you think that went?” or “Which aspects of that interaction went well? What would you want to do differently in the future?” List
one behavior that the learner did well and should continue, and one behavior that the learner should modify or not continue. Summarize two or three
key teaching points from the encounter.
2.
Elicit feedback about the session
Ask participants how they felt the session went. Make a specific plan to
overcome any shortcomings in the next session.
Summary
Effective bedside teaching is a valuable tool for attending hospitalists in
both community and academic practice. In the era of work hour restrictions for trainees in graduate medical education, teaching at the bedside
can be an efficient way to teach key competencies. Community hospitalists can also use bedside teaching to improve the skills of nurses,
physician’s assistants, and other practitioners. By following a simple
framework in which the hospitalist first sets the stage with learners, orients the patient, follows a pre-determined session structure, and debriefs
afterwards, hospitalists can optimize teaching at the bedside.
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S. Mookherjee and B. Sharpe
References
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Teach 25(2): 112–5.
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and psychological effects of the bedside presentation. N Engl J Med
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3. Lehmann LS, Brancati FL, Chen MC, Roter D, Dobs AS. (1997) The
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medical care. N Engl J Med 336(16): 1150–5.
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rounds and bedside case presentations: medical student and medicine
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6. Petersen K, Rosenbaum ME, Kreiter CD, Thomas A, Vogelgesang SA,
Lawry GV. (2008) A randomized controlled study comparing educational outcomes of examination room versus conference room
staffing. Teach Learn Med 20(3): 218–24.
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bedside teaching: findings from a focus group study of learners. Acad
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