Authors: Swayamjyoti Ray, Pial Ganguli
Publication date: 16 сен 2009
Why is it important and how can you improve it, ask Swayamjyoti Ray and Pial Ganguli
Bedside teaching is a specialised form of small group teaching that takes place in the presence of the patient. Although it is known to enhance a student’s learning experience and improve patient care, the use of this type of teaching is unfortunately in steady decline. As well as in the hospital setting, bedside teaching skills can be used elsewhere, such as long term care facilities and in the office.
Teaching starts with a lecture or discussion away from the ward followed by more interactive sessions by the patient’s bedside, making bedside rounds the most patient centred of all teaching venues.
Why is it important?
Bedside teaching can improve students’ history taking, examination skills, and knowledge of clinical ethics, can teach them professionalism, and can foster good communication and role modelling skills.    The educational sessions integrate theory, practical skills, and patient contact to make the educational process as realistic as possible, and they allow the students to develop empathy with the patients. Teaching small groups in the presence of the patient allows trainees to be closely observed and taught clinical practice and medical examinations.
Rather than listening to a presentation or reading from a blackboard, learners have the opportunity to use most of their senses—hearing, vision, smell, and touch—to learn more about the patient and his or her problems. I experienced this during the early years of my training with the first patient I admitted with pancreatitis—the smell of alcohol on the breath, the dry tongue, and the decreased skin turgor. By the bedside, I also learnt about the pigmented spots around the umbilicus in severe haemorrhagic pancreatitis and Rovsing’s sign in acute appendicitis. These experiences create hooks upon which a great deal of clinical learning can be hung.
How is it done in current practice?
I have experienced bedside teaching both as a learner and as a teacher in a hospital ward and have found that groups of fewer than six people (including the doctor-teacher) work best. Having a small group prevents disruption to other hospital staff within the ward. It also promotes discussion and active participation, keeps noise levels to a minimum, avoids overcrowding, and ensures less distress to patients.
Where are we now?
In clinical medicine, 56% of patients’ problems can be diagnosed after taking a comprehensive history, and this rises to 73% by the end of a physical examination.  However, Tremonti and Briddle found that the median time trainee doctors spent at the bedside was only 2.5 minutes, compared with 69 minutes in the classroom. 
Along with this decrease, a decline in overall clinical skills among trainees and junior faculty members has been observed. Fitzgerald stated that “the farther away from the bedside we go, the less opportunity our students have to observe experienced clinicians exercising their skills in the diagnostic and therapeutic relationship with patients. Only at the bedside can such skills be taught.”
The importance of the correct application of clinical skills has been recognised by the Modernising Medical Careers taskforce, who have introduced various methods of formally assessing the clinical techniques of doctors, including the direct observation of procedural skills (DOPS) and the mini-clinical evaluation exercise (mini-CEX). In addition, all the medical schools and the royal college examinations invariably have practical aspects (objective structured clinical examinations), and patient interaction is an essential component.
Barriers to bedside teaching and how teaching can be improved
Various obstacles that prevent doctors from teaching at the bedside have been cited,   and a considerable number of studies have stated “lack of time” as the single most important factor.  Possible reasons for this are the increased pressure to see more patients, more demand for paperwork, rapid patient discharge, and over-reliance on technology.
Some doctors believe that patients might object or feel uncomfortable with bedside teaching. An article published by the BMJ in 1968, however, said that 93% of patients did not object to students being taught at the bedside. In fact, the patients love the attention and even feel that the doctors are communicating with them and are interested in them. 
Students and physicians can feel “exposed” in the presence of a patient, but a study by Wang-Cheng and colleagues found that 85% of the patients preferred bedside rounds compared with 35% of the physicians.
Some doctors feel that the presence of family members creates an invasion of privacy and is an impediment to bedside teaching; however, Muething and colleagues found that the presence of family members does not seem to negatively affect learning. Despite the initial concerns of staff members, family centred rounds have become widely accepted, especially in paediatrics. The involvement of the family in the decision making process has offered a new learning experience for doctors and students.
Many teachers feel uncomfortable in the role of bedside teacher. Lack of experience, unrealistic expectations, and discomfort with teaching in the presence of a patient can lead to their reluctance to teach at the bedside, and clinical teachers do not usually have any formal briefing on the students’ curriculum and even less knowledge about clinical teaching methods.
Strategies to increase bedside teaching
Expert educators on bedside teaching have recommended many strategies.   Preparation and planning bedside rounds are key elements. The time period for teaching should be protected both for the learners and the teacher, and teachers need to familiarise themselves with the clinical curriculum and find out about the level of the learners’ clinical skills.
Team ground rules must be established before visiting a patient’s bedside, and the learners should be briefed about the objectives. They also have to be made aware about the level of sensitive discussion that should take place in the presence of the patient.
It is extremely important to introduce the key members of the group to the patient. The patient’s permission must be sought and they must be informed about the teaching session.
Observing the trainee’s interaction with the patient can help teachers to evaluate trainees’ clinical skills, bedside manner, professionalism, attitude, and knowledge.  Every learner should be given the opportunity to participate and the teacher should try not to ask excessively difficult questions that may demoralise a student.
At the end of the teaching session there should be a feedback session to summarise what has been taught, and adequate time should be available for discussion.  The teacher should reflect on the teaching encounter in order to improve and better prepare for the next encounter.
Although bedside teaching is an important aspect of clinical education, increasing pressures on clinical practitioners have resulted in a fall in its use in recent years. This needs to be addressed by providing more structured and protected bedside teaching opportunities for students and junior doctors.
Example of the advantages and disadvantages of bedside teaching
A patient with an acute abdomen was admitted to the surgical unit. I was one of four students attending ward rounds with the professor of surgery and was asked to take the patient’s history and examine him. The 46 year old man had woken the previous morning with pain in his abdomen that had become progressively worse, making him unable to walk or move. He also felt dizzy.
On examination, he had a fast pulse rate, slightly lowered blood pressure, and a tense abdomen. I presented the history and these findings to the professor who then asked me for a diagnosis. I suggested appendicitis, which I was asked to justify. I attempted to do so but was not able to offer sufficient explanation. The professor then took a thorough history, looking for any relevant physical signs before starting a structured clinical examination. He asked us about the subtle bluish discoloration near the patient’s umbilicus and what it represented. Before we could answer his pager went off and he left.
On his return to the ward 15 minutes later, he asked us again about the sign. Our inability to answer in front of the patient made us feel exposed. After gathering courage I said, “Blumberg’s sign.” The professor was not impressed and said that it was imperative that all fifth year medical students knew the sign he was talking about—he did not realise that we were third year students and had been posted to the surgical ward just seven days previously. He described the discoloration as Cullen’s sign, which is seen in severe haemorrhagic pancreatitis. He placed his hands on the patient’s abdomen and demonstrated to us where to feel for an expansile mass for an aortic aneurysm—a differential diagnosis for acute upper abdominal pain.
Later in the doctors’ room, we discussed the required investigations but again our discussion was cut short as the professor left for a managerial meeting.
The teaching session was instructive, and I have never forgotten the process of diagnosing an abdominal aneurysm. I was taught the importance of history taking before beginning a physical examination, and I learnt about professionalism and empathy towards the patient. I did feel, however, that discussion beforehand with the professor would have benefited all of us. Time constraints meant that not everyone got to examine the patient and we did not get any feedback on our performance. Protected teaching times would have addressed this and ensured an uninterrupted experience.
Competing interests: None declared.
Patient consent not required (patient anonymised, dead, or hypothetical).
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Swayamjyoti Ray teaching and research fellow
Department of Surgery, James Cook University Hospital, Middlesbrough TS4 3BW
Pial Ganguli medical journalist Cheshire