Foundation doctors and bedside teaching
Authors: Oliver Tavabie, Paul Baker
Publication date: 30 Mar 2011
Oliver Tavabie and Paul Baker look at skills and competences for junior doctors who teach at the bedside
Doctors have a professional obligation to contribute to the training of other doctors, medical students, and non-medical healthcare professionals. These skills are not innate but can be learnt, and professionals who do teach must develop and maintain these skills. However, most foundation trainees leave medical school with little formal training in teaching. As students, they are left to create their own style by trial and error and from emulating role models. Potentially, bad practice could develop if no feedback is given.   
Teaching role of foundation trainees
“How do you rate this doctor in their willingness and effectiveness when teaching or training colleagues?” This is one of the competences in the mini-peer assessment tool highlighting the importance of teaching for foundation trainees. Many trainees will teach medical students in their job. Most teaching by foundation trainees is done with small groups of medical students on the ward or at the bedside. Bedside teaching brings together the “learning triad” of patient, learner, and clinical teacher. This is highly valued by the students, who see the foundation trainee as their most important clinical trainer. So here we mainly deal with the skills required in these informal sessions.
Skills required by foundation trainees to be bedside teachers
Miller’s pyramid  requires teaching, demonstration, supervision, and constant feedback for successful learning (figure 1).
For the medical student to achieve this at the bedside, the foundation trainee must:
• Have a practical and theoretical understanding of the topic being taught
• Assess the students’ needs
• Create a good learning relationship, and
• Plan the teaching session.
Practical and theoretical understanding of the topic
A sound knowledge base is required. Medicine is a rapidly moving field, and keeping up to date is imperative to maintain clinical practice and to teach good practice to others. Knowing your own limitations is part of this—for example, it would be inappropriate and poor role modelling for a foundation trainee to try to teach a student coronary artery bypass grafting. Foundation trainees are capable of teaching on many topics, practical and theoretical, and it is important to emphasise both aspects, as it is necessary for future doctors not only to understand practical aspects but to be able to put the information gained in a theoretical framework to guide their practice. Figure 2 shows the theoretical and practical weighting of some topics that foundation trainees are able to teach. For instance, being able to assess arterial blood gases does not help the patient if the doctor is unable to interpret the result.
Interest in the topic is vital. Teachers who convey their interest in the topic inspire their students to learn more, while those who seem uninterested can demotivate their students.   A lack of interest may be because of the subject matter or be due to an unwillingness to teach.
Even when a bedside teacher is competent clinically, a basic understanding of educational theory and training in teaching is also essential. There is little evidence relating to the skills required specifically for effective bedside teaching.
Assessing students’ needs
It is important to understand and cater to students’ learning needs. Their main concern may be to pass examinations as well as to prepare for clinical practice. They may have objectives set for each attachment, which can be useful in devising a curriculum. It is vital for foundation trainees to have an understanding of each student’s curriculum, as this will have great effect on what is taught. Each student is an individual and may have particular needs. Learning contracts at the beginning of the teaching relationship, where objectives are agreed for the teaching, maximise learning but must be flexible.
Good learning relationship
A good learning relationship is created by a number of means. Be open and welcoming, and avoid prejudicial attitudes and assumptions that exclude learning opportunities.  Certain personality traits—patience, consideration, emotional stability, maturity, sound judgment, being unconventional or experimental—may create bedside teachers who are more effective, but the evidence is conflicting.    What is clear is that creating an environment for interaction where students participate actively is the most effective way for learning to occur. The tutor should challenge students to think, in an atmosphere that allows questions. Good communication skills are important.
Maslow describes learning needs in detail. Some are internal, such as self respect. Others are external: esteem needs (which the bedside teacher can best meet by recognising and congratulating good efforts), safety needs (by providing an environment where the students and patients feel safe), and physiological needs (by planning sessions so the students do not tire). In small groups, friendships and camaraderie can develop if supported by the teacher.
Motivation and feedback are important to facilitate effective learning.  Recognising success and giving positive feedback are vital for this. But the greatest challenge is maintaining a supportive environment where negative feedback is needed.  Chambers and Wall  suggest key points in giving feedback (box).
Key points in feedback
• Give feedback as soon as possible after the event and allow adequate time for discussion
• Let the student comment on their performance first
• Teacher comments second
• Give positive feedback before negative feedback
• Use specific examples that were noted during performance
• Criticism should be constructive, and a plan should be set out to rectify issues that may have arisen
Feedback is informative for the student and the bedside teacher too. Rigorous appraisal of the learning relationship for both parties ensures the best outcomes in regard to learning contracts. 
Planning the session
Effective planning of teaching sessions is important, and this is often a weakness of many bedside teachers. This planning includes teaching preparation, the session itself, feedback after teaching, and suggestions for further development for both student and foundation trainee, as discussed above.
Students gain more if they know what their teaching session is about and are directed to appropriate resources. Liberating Learning emphasised the need for formal bedside teaching to be carefully prepared and set in a protected time. This gives less weight to impromptu bedside teaching and more to the creation of a learning contract, as mentioned earlier, and creating a curriculum designed to achieve it. Organisational and time management skills are important for the foundation trainee. Protecting the session time is important, as cancellations devalue the student’s position, and disruptions affect the quality of delivery. Careful case selection to fit the objective is important: select patients who have good histories or signs, or both, but who are also friendly, available, and willing.
Teaching needs to be at an appropriate level, not just the content but the terminology used. A first year student may need to have the word “hypokalaemia” explained, but a final year student given such an explanation may feel underappreciated. With bedside teaching it is particularly important that the number of students being taught is kept to a minimum. This is because it is a hands-on form of teaching where too many students might upset the patient or reduce potential learning experiences for all the students concerned. Information should focus on salient points, with use of further reading for full knowledge of the topic.
Quiet environments are best for learning, which can be difficult in a working hospital. Avoid teaching sessions during visiting hours, and arrange for them to be bleep-free. It is important that the session runs at the correct pace, in a logical order, and allows opportunities to ask questions. A cue sheet may be recommended to foundation trainees who think that they may lose their way during a session or be distracted by students’ questions.
Styles of teaching
The foundation trainee can adopt a few different teaching styles at the bedside. One is shadowing, where the student observes the foundation trainee doing a task and a discussion about it follows; direct observation is where the foundation trainee observes the student performing a task while discussing the case; and reporting back is where the student does the task without the foundation trainee present and reports back on completion. If the student excels at the task, it may be suggested that he or she teaches a fellow student, under observation by the foundation trainee. This is in keeping with the traditional teaching style of “see one, do one, teach one.” However, the patient must not be put at risk, so it is up to the foundation trainee’s judgment as to how far along this pathway the student can progress. This will vary from task to task. For instance, in a cardiac examination the student may be able to progress to teach peers, but with arterial blood gas assessment it would be an unacceptable risk to leave the medical student unsupervised. Figure 3 shows a sample bedside teaching plan on anaemia for three students.
Combining the learning world with the working world increases knowledge about how to perform a task and also why you perform a task. Appropriate involvement in the care of patients, with adequate supervision to ensure the patient’s safety, can maximise students’ learning outcomes..   
How foundation trainees can improve their teaching skills
Training in medical education is an excellent way to develop foundation trainees’ teaching skills. Many universities offer courses, ranging from certificates in medical education to doctorates.        Most courses require attendance at face to face sessions, which foundation trainees may find difficult. Annual course costs are usually about £1000, a considerable investment for a foundation trainee. The University of Dundee course “Introduction to medical education” seems “foundation trainee friendly” as it is available by distance learning with online support. It covers fundamental medical education topics such as curriculum development, assessment, teaching and learning (including bedside teaching skills), and research. The assessments are done by a short assignment, and the course is self directed, with a maximum time to complete a postgraduate certificate of four years. Such in-depth courses are probably too much for the foundation trainee wishing just to improve bedside teaching skills. There may be a niche for courses catering for this need.
We have already mentioned the traditional trial and error and emulating role models in foundation trainees developing their own teaching style. Delivering teaching with added feedback from experienced colleagues provides excellent learning for the foundation trainee to reflect on. However, without feedback it is possible that bad habits among seniors who are not effective at teaching will be perpetuated.   Furthermore the introduction of the European Working Time Directive has triggered discussion of its negative effects on training, especially in busier specialties such as accident and emergency. 
Becoming a member of an educational body such as the Association for the Study of Medical Education is also a good way to keep up to date with developing educational techniques and research and to be informed about the availability of activities to improve teaching knowledge.
Each of these means of improving teaching skills has positive elements, and a combination of them is likely to produce the best bedside teachers.
Competing interests: None declared.
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Oliver Tavabie foundation year 1 doctor
Royal Bolton Hospital NHS Foundation Trust, Bolton, UK
Paul Baker foundation school director North Western Deanery, Manchester, UK