He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.William Osler
Students learn what it means to be a doctor at the bedside. Communication, professionalism, clinical reasoning, and the physical examination are best learned in the presence of patients. In this setting, students are able to make connections and apply what they learned in the classroom to the patient who is with them.
In this article, we continue the series by the Council on Medical Student Education in Pediatrics in which the skills and strategies used by great clinical teachers are described. In previous articles, we considered specific strategies to teach family-centered care,1 clinical reasoning,2 and humanism3 at the bedside of patients. In this article, we provide practical tips to help busy clinicians incorporate bedside teaching into inpatient and outpatient care.
In our age of time pressures in clinical settings, multitasking, and short attention spans, clinical teachers face a challenging situation: how can they grab and maintain their learners’ focus during patient encounters? The great news is that short clinical teaching at the bedside is likely to captivate students because they have become accustomed to communicating through texts and tweets. We reframe the challenge of “not having time to teach” to finding content for timely teaching; in just a few minutes, great clinical lessons can be taught from every bedside.
Prepare Yourself and Your Team
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.
Compare and Contrast
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?
Don’t Limit Your Teaching to the Reason(s) the Patient Is in the Hospital or Clinic
Great clinical teachers see teaching and learning opportunities everywhere. They are not restricted to discussing the disease of the patient before them.
Teach About Anticipatory Guidance
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.
Teach About Development
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?
Teach About Nutrition
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
Think Out Loud
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.
Recall the Great Learning
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.
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POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
Balancing teaching and patient care in the inpatient unit
Bannister et al provided a great overview of bedside learning, part of an ongoing series from COMSEP on undergraduate medical education. Kudos to Pediatrics for featuring medical education at the student and and residency levels!!!
A couple of additional points about bedside teaching That I have learned from experience and theoretical constructs such as adult learning principles(1).
1. Hospitalized children are admitted because of severe illness and complex medical problems. Rounding time is, for the most part, directed toward patient care. Making teaching points brief but consistent (i.e., every day) is what learners remember, even when the service is beyond busy. 2. As a ward medical office before the days of the hospitalist, I made teaching learner-centered and taught around issues the students generated, not imposing my agenda on what I thought they needed to know.An example would be that the student presents a patient's lab data, including electrolytes with a low potassium. I use that critical incident to ask why the potassium might be low. That question and answer might have significant clinical implications about patient care and treatment. Therefore, I did not prepare for my teaching as the article suggests but waited for those critical incidents to occur and based my teaching on those, all of which were directly patient-related. 3. Students can help set the learning agenda by scribing questions they have about patients where there is little time to discuss these points on rounds. Once a week students and faculty can then discuss these issues in a session outside of rounds. 4. Every student learning opportunity on rounds requires student-generated objectives, often times further reading within the context of patients they have seen in order to complete the learning cycle. Rounds become a vehicle for further self-directed learning, again an adult learning principle. 5. Lastly, when students ask questions on rounds, it is so easy for faculty to want to answer first as the authority figure. Instead, try deferring the question back to the student that asked it, or to others in the group before you opine.
In essence, I have found these principles to be helpful in making learning on rounds student-centered and effective without extending the length of the session.
1. .Ottolini, M. C, Ozuah, P. O, Mirza, N, & Greenberg, L W Student perceptions of effectiveness of the eight step preceptor (ESP) model in the ambulatory setting. Teaching and Learning in Medicine 2010; 22(2), 97-101