Teaching ToolboxTeaching at the Bedside

R id A h RAResidents As Teachers – RATs

Miriam Bar on MDMiriam Bar‐on, MDAssociate Dean for Graduate Medical Education

Contributions from Heather A. Thompson, MDUniversity of Minnesota

For the junior student it is a safe rule toFor the junior student…it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taughttext, and the best teaching is that taught by the patient himself.

Sir William Osler, 1903

Objectives Objectives

Recognize the importance of teaching at theRecognize the importance of teaching at the bedside

Discuss the two primary aims for teaching atDiscuss the two primary aims for teaching at the bedside

D l l d h d i l d b d idDevelop a planned method to include bedside teaching as part of instruction for the students

IntroductionIntroduction

Many benefits of bedside teachingMany benefits of bedside teaching

Frequency of bedside teaching is decreasing

h i d S l h 2 % f li i lIn the United States, less than 25% of clinical teaching occurs at the bedside

Introduction Introduction

Less than 5% of time is spent observingLess than 5% of time is spent observing learners’ clinical skills and correcting faulty exam techniquesexam techniques

With current hospital environments, barriers have increased and the opportunity forhave increased and the opportunity for bedside teaching have decreased

IntroductionIntroduction

Bedside teaching if not done correctly can beBedside teaching if not done correctly can be very boring for some learners

Key is to keep all engagedKey is to keep all engaged

Focus needs to be on the learners and not the h i k i LEARNERteacher – i.e. keep sessions LEARNER 

CENTERED

Why Teach at the Bedside?Why Teach at the Bedside?

Provides the opportunity to observe, teach,Provides the opportunity to observe, teach, correct and practice physical exam skillsReinforces skills of medical interviewing,Reinforces skills of medical interviewing, communication and patient education –obtain additional information from the patientHumanizes care by involving the patientModels the professional interaction betweenModels the professional interaction between patients and teams in a teaching hospital

Why Teach at the Bedside?Why Teach at the Bedside?

Allows teaching to be integrated into activities g gresidents do everyday – speaking to and examining patients

l k d f h dLearners like demonstration of the doctor‐patient relationship and other psychosocial aspects of patient careaspects of patient careEngages patients and includes them in their care and in the learners’ learninggImproves patients’ understanding of their illnesses

BarriersBarriers

Fear of patient discomfortFear of patient discomfort

Lack of privacy and/or confidentiality

bl l i iTrouble locating patients

Learners do not want to go to the bedside

Takes more time

Teachers feel uncomfortable – i e may lead toTeachers feel uncomfortable  i.e. may lead to a discussion of medicine teacher not comfortable withcomfortable with

ExerciseExercise

Before getting started in learning strategiesBefore getting started in learning strategies about bedside teaching consider the following:following:– Recall a bedside teaching session that was effective. What made it go well?effective.  What made it go well?

– Recall a bedside teaching session were learning was minimal.  What made this session ineffective?as a a ade s sess o e ec e

12 Tips to I B d id T hiImprove Bedside TeachingSet of strategies to use in teaching at bedsideSet of strategies to use in teaching at bedside

Divided into 3 time periods:P R d– Pre‐Rounds

– During Rounds

– Post‐Rounds

Pre-Rounds: PreparationPre Rounds: Preparation

Preparation is a key element for conductingPreparation is a key element for conducting bedside rounds and increasing teacher comfortcomfort– Determine which patients would be good bedside teachingteaching

– Ask the patient if okay to teach with him/her

– Practice skills if uncomfortable with them or in– Practice skills if uncomfortable with them or in front of a group

Pre-Rounds: PlanningPre Rounds: Planning

Draw a roadmap of what is to beDraw a roadmap of what is to be accomplished with the session at the bedsideConsider emphasis of the session –Consider emphasis of the session – Physical exam skills– Interviewingg– Patient education

What is the mission of the session –What is the mission of the session – Demonstration of a skill– Observation of performance of a skillp

Pre-Rounds: OrientationPre Rounds: Orientation

Orient the learners to the plans for theOrient the learners to the plans for the bedside teaching session

Outline goals/learning objectivesOutline goals/learning objectives

Establish rules for the session

Inform the learner(s) of expectations during the session

If there is information that will not be discussed, inform all participants, p p

Rounds: IntroductionRounds: Introduction

Introduction of self and all learners by namet oduct o o se a d a ea e s by a e– That engages the learners immediately– Helps patient understand everyone’s role

Explain the session to the patient and its purpose (in front of all learners)If “jargon” will be used, explain that to the patient

if i l i d d– Best if sessions use language patients understand– Best if “what‐if” conversations are not in front of patientspatients

Rounds: InteractionRounds: Interaction

Role model a physician‐patient interactionRole model a physician patient interaction

Patients like being in the limelight and enjoy participating in bedside roundsparticipating in bedside rounds– Perception that physicians are interested in them

M k ib i h d i f f– Make a contribution to the education of future doctors

G i h f i li bGreat opportunity to teach professionalism by role modeling and NOT by lecture

Rounds: ObservationRounds: Observation

Focusing on the learner through keen ocus g o t e ea e t oug eeobservation is part of “learner‐centered” teachingObserving the learners’ interaction with a patient can be very informativeSpecific skills on which to focus:– Communication (interviewing, explaining, etc.)P bl l i kill– Problem solving skills

– Medical knowledge– Attitudes– Attitudes

Rounds: Instruction Rounds: Instruction Challenge the learner(s) mind(s) without g ( ) ( )humiliating and gently correct mistakesAvoid the famous “read my mind” type of questionsquestionsDiscourage “gunner” behaviors between the learners if in a grouplearners if in a groupTeach and model professionalismDemonstrate physical exam skills p yAvoid giving a long lectureCapture teachable moments – often unplanned

Rounds: SummarizationRounds: Summarization

Review with the learners what they wereReview with the learners what they were taught 

Summarize teaching and learning points inSummarize teaching and learning points in front of the patient before leaving the room

P i d i b d hi i ifPatient education can be done at this point if indicated

Post-Rounds: DebriefingPost Rounds: Debriefing

Leave time after leaving the room for learnerLeave time after leaving the room for learner questions, further discussion, and potential reading assignmentsreading assignments

If the encounter was intense, allow learner(s) to discuss what happened and their feelingsto discuss what happened and their feelings –critical in the learning process

Post-Rounds: FeedbackPost Rounds: Feedback

Assess the sessionAssess the session – What went well

What did not– What did not

Feedback session should remain brief and f t th f th i dfocus on strengths of the session and deficiencies that need improvement

Determine what should be modified for the next bedside teaching session

Post-Rounds: ReflectionPost Rounds: Reflection

This step is separate from feedback as it isThis step is separate from feedback as it is exclusively for the teacher

Again what went well and what did notAgain what went well and what did not

What should be changed the next time b d id dbedside rounds occur

Look at strengths and areas needing improvement of the teacher

Post-Rounds: PreparationPost Rounds: Preparation

Post reflection is the perfect time to beginPost reflection is the perfect time to begin  preparation and planning for the next session

A few simple notes to self (teacher) will startA few simple notes to self (teacher) will start the process and focus on what should be kept and what needs to be changedand what needs to be changed

ConclusionsConclusions

Bedside teaching is an important method ofBedside teaching is an important method of teaching your learners

There are many skills that just cannot beThere are many skills that just cannot be taught without a patient

Th i b l f h hThere is no one better to learn from than the patient

Without patients there is no need to learn

To study the phenomenon of disease withoutTo study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go tostudy books without patients is not to go to sea at all.

Sir William Osler 1903Sir William Osler, 1903

Good Articles Good Articles

Janicik RW Fletcher KE Teaching at theJanicik RW, Fletcher KE. Teaching at the bedside: a new model. Medical Teacher. 2003;25:127‐1302003;25:127 130.

Ramani S. Twelve tips to improve bedside teaching Medical Teacher 2003;25:112 115teaching. Medical Teacher. 2003;25:112‐115.

Please click on the link below to take the assessment.

Presentation AssessmentPresentation Assessment