Just Do It: Incorporating Bedside Teaching Into Every Patient Encounter

Experienced clinical teachers consult their patient list in advance and think about short teaching points based on the patients they will encounter in the clinic or during rounds. With these potential teaching points in mind, great clinical teachers focus their attention on creating a comfortable learning environment.⁴ They may search for and print clinical guidelines or review articles for their students. Preparation, however, is primarily about getting in a positive frame of mind and walking into patient encounters with an open mind, ready to see (and seize) learning opportunities.

Clinical teachers prepare students for bedside teaching in several ways: they ensure introductions are made so that learners can identify others and their roles; they ask students if there are particular skills for which they would like to receive feedback; they remind their teams to simultaneously attend to the family’s and patient’s responses and that teaching sessions may vary in length or end abruptly, depending on what unfolds; they outline guidelines for which information should not be discussed in front of the patient and family; they orient their learners to their teaching style; and they commit to not embarrassing their learners and tell them they will use a phrase such as “Let me show you another way to do that” if a student does something incorrectly.

As you see patients together, ask your learners to compare different diagnoses or the same diagnosis in different ages or types of patients. Consider the following questions that could be asked during an encounter with a patient in respiratory distress:

• How does this child’s respiratory examination differ from the examination of our patient who has croup?

• Which clues from the physical examination make us suspect this infant has pertussis? What would make us think of bronchiolitis?

• What would you consider if this child had been coughing for only a few hours? For a few weeks?

• How would the respiratory examination be different if this child was an infant? An adolescent?

• How would this disease present if this infant had a congenital heart defect?

Great clinical teachers see teaching and learning opportunities everywhere. They are not restricted to discussing the disease of the patient before them.

Use your clinical encounters to model and teach anticipatory guidance. If an infant is sleeping with a bottle in his or her bed, capitalize on the opportunity to discuss sleeping and dental hygiene. Talk to children and their parents about screen time when you see a child on any electronic device. Discuss choking hazards when the toddler is sitting in bed or in a chair eating.

Ask team members to observe an infant or child, report on what the patient is able to do in each of the developmental domains, and then have them guess the patient’s age. Ask trainees to compare what the patient before them can do versus what a child of this age should be able to do. Discuss how a child’s development might be affected by their health condition and how observations about a child’s development might be affected by the child’s current experience in the hospital or clinic. As mentioned above, ask the trainees to compare patients: How do this child’s language skills differ from the skills of the patient we just saw? Why?

Discuss appropriate (and inappropriate) nutrition in the context of what you observe the patient eating. With infants, talk about which types of foods would be the most appropriate to introduce next. Model ways to ask parents and children about what their typical diet is like and ways to incorporate nutritional suggestions in conversations with parents and patients.

Great clinical teachers broaden the teaching of medicine by discussing strategies to develop differential diagnosis,⁵ limit cognitive bias,⁶ and search for clinical answers in the literature.⁷ They discuss sensitivity and specificity of laboratory results,⁸ the cost of investigations,⁹ and communication strategies.¹⁰ 

Be explicit with your students; think out loud¹¹ and articulate how your clinical reasoning is changing as more information is learned. Great clinical teachers can explain how the components of the patient’s history and physical examination lead them to make diagnoses. Examples of statements that could be articulated during an encounter with a child in respiratory distress include the following:

• Now that we’ve learned there is a positive history of asthma and eczema, I am more likely than before to think that this child has asthma.

• This child has audible wheezes. I am considering a diagnosis of a lower airway disease.

• The lack of wheezes doesn’t rule out asthma in my mind; maybe this patient is not moving much air at all right now.

One of the most overlooked elements of bedside teaching is the necessity to reflect on the encounter.¹² A few minutes are needed to reflect on events during the encounter. Often students may not have noticed or appreciated specific events that can be brought to their attention. Feedback immediately after an encounter tends to be specific and thus more valuable.¹³ Give students an opportunity to articulate simple learning goals that relate to the day’s learning, such as looking up a clinical guideline or reviewing developmental milestones.

Remind trainees about the key learning acquired that day or ask them to keep a list of things they learned. In the midst of patient care, learners may be challenged to recall the teaching they experienced. Assess the session by requesting feedback and asking, “Next time we are at the bedside, should we do anything differently?” and “Did we achieve our goals for today?” Use this information to revise your future teaching sessions.

Medicine is learned at the bedside and each patient has a lesson to teach. In just a few minutes, great clinical teachers can direct students’ attention to what is important while simultaneously providing clinical care. Timely teaching is a critical component of the tool kit of a great clinical teacher.