Chapter 4Bedside Teaching:

Recovering a Lost Art

Faculty Development Series Madigan Healthcare System Tacoma, Washington 98431

Bedside Teaching

Chapter Contents

Group Leader ChecklistLearner Needs and Resources Assessment (LNRA)

Attendance SheetEvaluation Form

Example Eight StepsHandout

Summary of Supporting References and Resources

Checklist for the Group Leader

Before the Session....

___ 1. Review the suggested eight steps of planning for this presentation.

___ 2. Review the PowerPoint, handouts, and supporting references in this chapter.

___ 3. Duplicate and distribute the LNRA to faculty.

___ 4. Have faculty return the LNRA at least 5 days before the session.

___ 5. Review the faculty LNRA prior to the session.

___ 6. Modify the suggested eight steps and write your plan to fit your needs.

___ 7. Modify the PowerPoint and handout to fit your plan.

___ 8. Duplicate the appropriate number of copies of the attendance roster, faculty evaluation forms, and handouts.

During the Session....

___ 9. Have each participant sign-in using the attendance roster.

___ 10. Distribute the handout(s) to the participants.

___ 11. Conduct the session based on your eight steps of planning.

After the Session....

___ 12. Collect the evaluation forms from the faculty.

___ 13. Keep the attendance roster for the session in your department and provide the appropriate amount of CME to each participant.

___ 14. Reflect on the seminar - How did it go? What was good about it? What could have been better? Is there a better approach to this topic? Were there needs identified during this session that would be the basis for future seminar(s) in your program?

___ 15. Where will your program go from here based on this seminar?

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Learner Needs and Resources Assessment

Please complete the following needs assessment for the upcoming workshop on Bedside Teaching: Recovering a Lost Art as part of your faculty development program.

The seminar will consist of an introduction by your group leader, a short PowerPoint presentation and interspersed small group activities and class discussions.

The purpose of this needs assessment is to determine your learning needs and interests, so that the seminar is most useful for you. This needs assessment should also stimulate you to think about active learning before the seminar begins. We need your enthusiastic participation now, and in the seminar. It will be fun, and at the end of it, we'll be asking for your feedback!

Please turn this in to your group leader (______________) no later than (_____________).

1. Have you had any formal training in bedside teaching? YES NO

2. What are some advantages to teaching at the bedside?

3. What are some barriers to bedside teaching at your hospital?

4. Think about the bedside teaching rounds made in your program. Who does them? Are they effective? What are the strength(s) of bedside rounds in your program, and which areas need improvement? Be prepared to share your thoughts with the group during the seminar.

5. List three things you would like to learn/take away from this session:

a.

b.

c.

Any other comments / concerns for this presentation:

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ATTENDANCE ROSTER – Page____of_____Pages

Department: ____________________ Institution:____________________Title of CME Activity: Faculty Development Series – Bedside Teaching: Recovering a Lost Art

Course Content: Didactic and Group Discussion – Instruction on Bedside Teaching techniques and strategies to systematically implement Bedside Teaching

Instructor (Group Leader):____________________________

Date:____________ Time: Began___________ Ended________ Total ___________

Name RankCheck One

Department or Mailing AddressStaff

PhysicianResident Physician

Other Professional Discipline

Total Number of Learners Attending This Activity: _________

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Faculty Development Session Evaluation Form

Date Speaker Topic

Please rate the speaker using the scale below:

Strongly Disagree

Disagree

Somewhat Agree

Agree Strongly Agree

Content was relevant to my needs

The speaker conveyed the subject matter clearly

The speaker used active learning techniques to teach this subjectThe speaker gave adequate time for questions

Audiovisual / handout material added to the presentationOverall, the speaker was effective

List one thing that you learned from this presentation:

Please add your comments/suggestion for improving this session on the back—they are VERY helpful

Faculty Development Session Evaluation Form

Date Speaker Topic

Please rate the speaker using the scale below:

Strongly Disagree

Disagree

Somewhat Agree

Agree Strongly Agree

Content was relevant to my needs

The speaker conveyed the subject matter clearly

The speaker used active learning techniques to teach this subjectThe speaker gave adequate time for questions

Audiovisual / handout material added to the presentationOverall, the speaker was effective

List one thing that you learned from this presentation:

Please add your comments/suggestion for improving this session on the back—they are VERY helpful

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Bedside Teaching

Example Eight Steps

The eight steps presented below may be used as a guide for your planning.Modify these steps to meet your specific needs.

Who: 8-10 faculty learners from the Department of Family Medicine

Why: Enhance clinical teaching as part of a required faculty development curriculum

When: 1400-1500 on a Thursday afternoon, blocked schedule for faculty development

Where: Classroom, individual desks, accessible, AV supported, requires own computer

What: Driven by the LNRA. How to plan and execute bedside rounds. Models to cover include: Ramani model (12 steps), Janicik model (3 domains). Identify barriers to implementation and explore strategies to overcome them. Commit to an implementation plan for the group.

What For: By the end of this session, we will have:

• Listed obstacles to bedside teaching• Identified advantages of bedside teaching• Tried out models for bedside teaching• Found ways to overcome obstacles• Planned integration of bedside teaching into inpatient rounds

How: General: Active learning: small group activities and discussion, larger group discussion, minimal PowerPoint slides. Room contains one large table with chairs, white board, smart board connected to computer. Will group chairs to form two groups of 4-5 learners each. This will facilitate small group activities followed larger group discussions. The session will take place at 1400, so will provide coffee and cookies.

Grabber: Osler quote “Medicine is learned at the bedside and not in the classroom.” Crumlish study numbers showing staff and residents value bedside teaching (may contrast with institutional experience/perceptions).

Induction Tasks: 1. Began with LNRA and continued in first activities. Learners reflect on their experiences with bedside teaching.

2. Learners discuss obstacles to bedside teaching. Write list on board/easel or other prominent site in room and keep visible throughout session. Use LRNA responses to jumpstart the conversation, starting with “time” (universal barrier).

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3. Learners discuss advantages to bedside teaching. Write and display as with obstacles above. Affirm the learners by comparing their list to data from the Crumlish study. Use LRNA responses to prepare slide.

Input Tasks:1. Introduce the Ramani and Janicik models described on the handout. Note that an excerpt from the models is also provided for the next task.

2. Have small groups review the models.

Implementation Tasks:1. Have small groups use a case from their experience to formulate a bedside teaching session using the excerpt from one model. Allow 15min for this task. Discuss what struck them about it at the end of the learning task.

2. Discuss potential solutions to obstacles they have identified. Note this may occur naturally at any point in the session.

3. Discuss any other issues identified in the LRNA not yet addressed, as time allows.

Integration Tasks:1. After reviewing and affirming the work of the learners to this point, discuss and commit (as a group) to a plan for implementation. Suggest inclusion of minimum baselines such as frequency, duration, site, and people included in bedside group. Note the need to remain flexible in day-to-day practice. Write their commitments on the board/easel/other prominent place. At the end of the session, copy this list.

2. One month after the session, e-mail the site POC for feedback on the session. Include their list of commitments from the session and request assessment of impact.

So What:Learning: Learners have identified obstacles to and advantages of bedside teaching. They have reviewed two models to plan and structure bedside teaching sessions. They have identified strategies to overcome obstacles to implementation of regular bedside teaching. They have committed to a plan for regular bedside teaching.

Transfer: Learners implement regular and effective bedside rounds into their inpatient care rotation. They continue to identify and seek ways to overcome obstacles.

Impact: Residents and other learners improve their understanding of and performance in many dimensions of medical care. Morale and enthusiasm for inpatient care, teaching and learning all improve.

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Bedside Teaching HandoutBlending Tradition, Humanity, Art & Science

“No books, no tapes, no audio-visual aids, no seminars, no avant-garde philosophy will ever be substitutes for the discipline of bedside medicine—the one-to-one situation where

tradition, humanity, art, and science are blended." ~Unknown

Bedside Teaching: The Imperative

94% of residents believe bedside teaching time is valuable82% want more bedside teaching in the curriculum

Crumlish, et al, 2009

Teachable moment: The moment when a unique, high interest situation arises that lends itself to discussion of a particular topic.

Breaking Down the BarriersBarriers Recommendations

Limited time Be selective: not every patientDon’t wait for a quorumBe flexible

Attending inexperience or fear Faculty DevelopmentAcknowledge self as “imperfect scholar”Share the teachingEncourage self-directed learning (SDL)

Perceived patient discomfort Ask permission85% of patients prefer bedside roundsEnhances patient and family centered care

Overreliance on technology Explain the importance of diagnostic skillsIncorporate the technology at the bedside

Learner resistance Be persistentInclude all learnersNever undermine the learner in front of

patient

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Seek and Make the Most of Teachable Moments

Provide Frequent and Timely Feedback to All Learners on Team

Prepare, Brief, Experience, and Debrief

Break Down Barriers with Flexibility, SDL, and Persistence

Take Learning to the Bedside

“The best teaching is taught by the patient himself.” ~ Sir William Osler

Small Group Teaching: The Basics

Learning Environment:Low pressure Stimulate discussion and doubt

Teach from the middle Encourage self directed learningEngage the learners / Share teaching Think out loud

Effective Feedback Principles (SOME TLC):Specific Timely

Objective LimitedModifiable behaviors Constructive

Expected (Frequent)

Provide Effective Feedback:Ask What did you do well? What questions or challenges did you have?

Tell / Teach I observed… Then give a few general teaching points.Ask / Act What will you do differently next time? Develop an action plan.

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Prepare Objectives:

- Identify target learners

- Determine teaching objective (e.g. interviewing, physical exam, interacting with family)

Brief Participants:

- Ask patient and explain event

- Brief learners:

- Discuss expectations

- Assign roles

Debrief:

- Ask learners for their observations

- Provide feedback

- Encourage self-directed learning

Clinical Experience:

- Explain

- Demonstrate

- Learner experiences

- Assess

The Teaching Cycle

Improving Bedside TeachingBreaking Down OUR Barriers

Task #1 Bedside Teaching where I work Task #3

Obstacles

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Solutions

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Bedside Teaching

Task #2 – Road Maps OR Focused Teaching – 15 minutes

RAMANI MODEL: Draw a road map (steps 1-4), orient learners (steps 5-7)

1) Medical system to be covered

2) Skills or aspects to be taught

3) Observation vs. demonstration

4) Define which patients and how long

5) Objectives, expectations, ground rules

6) Assign roles (presenters, examiners, jargon police, etc.)

7) Set limits (no coverage of highly sensitive issues, etc.)

JANICIK MODEL: Focused teaching (steps 1-4), Group Dynamics (steps 5-7)

1) Role model professional behavior, communication

2) Physical exam or procedural skills

3) Teach general concepts

4) Give feedback (patient can also give feedback)

5) Limit the time and goals for the session

6) Include everyone in teaching and in feedback

7) Assign roles to everyone

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Pick ONE model below. Use a case you have seen on the ward.

Work through the steps listed as if you were going from here to rounds.

Bedside TeachingReference model #1

The 12 Step Model (adapted from Ramani, et al, 2003)

1) Prepare goals for the sessiona. Use the curriculumb. Meet the learners at their level

2) Draw a road map ***a. Medical system to be coveredb. Skills or aspects to be taughtc. Observation vs. demonstrationd. Define which patients and how long

3) Orient learners ***a. Objectives, expectations, ground rulesb. Assign roles (presenters, examiners, jargon police, timekeeper, etc.)c. Set limits (no coverage of highly sensitive issues, etc.)

4) Introductiona. Introduce whole team and road map to patientb. Note primary goal is teaching

5) Interaction – Role model professional behavior for the learners6) Observation – Step out of the limelight, support learner as primary caregiver7) Instruction – Challenge the learners intellectually, don’t humiliate them

“DO’s” “DON’Ts”Gentle corrections Keep team all engaged One upmanshipAdmit knowledge limits Learn from your students “What am I thinking?”Teach professionalism Teach hands-on skills Ask juniors after seniorsTeach observation skills Use teachable moments Long didactics

8) Summarization – Recap for learners and the patient

9) Feedback – From learners, what went well and/or not well10) Debrief

a. Time for questions/clarificationsb. Assign further reading/researchc. Discuss sensitive areas

11) Reflect12) Prepare for next time

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BEFORE

AFTER

DURING

Bedside Teaching Reference Model #2

The 3 Domains Model (adapted from Janicik, et al, 2003)

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Attend to Patient Comfort

1) Ask the patient’s permission in advance2) Introduce everyone on the team3) Start with a brief overview from the primary caregiver (learner)4) Give explanations without using medical jargon5) Base the teaching points on that patient6) Use a genuine, encouraging closure statement7) Return later to check for and resolve misunderstandings

Focused Teaching

1) Diagnose the patient2) Diagnose the learner3) Provide targeted teaching ***

a. Role model professional behavior, communicationb. Physical exam or procedural skillsc. Teach general conceptsd. Give feedback (patient can also give feedback)

4) Debrief after the session

Group Dynamics ***

1) Limit the time and goals for the session2) Include everyone in teaching and in feedback3) Assign roles to everyone

Supporting References and ResourcesBedside Teaching

Cox, K. (1993). Planning Bedside Teaching. The Medical Journal of Australia, Vol. 158-9.University of New South Wales School of Medicine. Series of 8 articles describing a teaching cycle in detail. Source for Teaching Cycle in the handout. Full conceptual diagram:

WorkingDebriefing Preparation knowledge

Clinical ExplicationEncounter

PreparationBriefing for next time Reflection

Crumlish, C. M., Yialamas, M. A., McMahon, G. T. (2009). Quantification of Bedside Teaching by an Academic Hospitalist Group. Journal of Hospital Medicine, 4:304-7.Author from Brigham and Women’s Hospital, Boston, Internal Medicine residency. Study examined time spent at the bedside during rounds (17%, deemed too low) and what residents value about bedside teaching.

Most valuable parts of BT:Physical ExamCommunication/Interpersonal skillsFocus on pt-centered careIntegrating clinical exam w/dx/mgmt decisions

Ende, M. J. (1997). What if Osler Were One of Us? Inpatient Teaching Today. Journal of General Internal Medicine, 12:S41-S48. Author from University of Pennsylvania School of Medicine. He examines challenges and planning modern bedside teaching using Osler as an example of excellent practice.

Principles of Learning Corresponding Rec’s for Teaching1) Knowledge is constructed, Begin with students’ conceptualization;

not accumulated Use probing questions; encourage reflection2) Expertise depends on experience Focus discussions on the patient;

with cases Teach at the bedside; compare/contrast cases3) Students learn when they Provide challenge and support; stimulate interest;

are involved Make rounds fun; encourage independent learning4) Learning is both a personal and Develop a learning community; provide orientation;

a social process Leaven credibility with authenticity; Know your learner

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Experience

Cycle

Explanation

Cycle

Ende, M. J. (1997). (con’t)Questions to guide planning “rounds that work”

What do you hope to accomplish?What is your point of view?How will your learners be engaged?How will you meet the needs of each learner?How will rounds be organized?Are your rounds successful?How will you make the time?

Gonzalo, J. D., Masters, P. A., & Simons, R. J. (2009). Attending Rounds and Bedside Case Presentations: Medical Student and Medicine Resident Experiences and Attitudes. Teach Learn Medicine, 21 (2):105-110. Authors and study from Penn State College of Medicine. 3rd year med students, Internal Medicine and Med-Peds residents surveyed about time, value and concerns over bedside rounds. Time at bedside: mean 27% of rounds (73% of rounds had <25% of time at bedside). Value: 1) Learners that had seen bedside rounds prefered bedside rounds more

than those who hadn’t seen them (42% vs 13%). 2) Bedside rounds somewhat or very important for learning physical exam (89%),

communication (83%), professionalism (72%), patient mgmt (59%), history-taking (55%), pain mgmt (43%).

Concerns: Prevents freedom of discussion about patient’s case (75%), patient comfort (66%), concern for patient’s feelings (66%)

Kroenke, K., Omori, D.M., Landry, F.J., Lucey, C.R. (1997). Bedside Teaching. Southern Medical Journal, 90 (11):1069-74. Primary author from USUHS, Dept of Medicine. Review of five common obstacles to bedside teaching and potential solutions for each:

Obstacle Potential SolutionsTime constraint Pre-designate time during rounds (30min/day, 1 pt/day, etc);

Be selective in target for each encounter

Selecting targets Attending picks based on presentation (confusing hx, abnormal exam);Attending asks team to pick; Someone notes a great learning point independently

Demonstrate vs. Demonstrate advanced skills;observe Observing residents slower but better learning

Staff insecurity "No finding is too mundane"; Chronic findings still valuable;Learn together as a team; Role model compassion/professionalism

Learner dislikes Plan ahead, limit single-resident exam timeBoredom Set the tone before bedside rounds; Teach vice putting on the spot;Fear of embarrassment Specify goals/agenda

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Janicik R. W., Fletcher, K. E. (2003). Teaching at the bedside: a new model. Medical Teacher, 25 (2):127-130.Source for model cited in handout.

Lehmann, M. L., Brancati, M. M., Chen, M. M.-C., Roter, D. D., & Dobs, M. M. (1997). The Effect of Bedside Case Presentations on Patients’ Perception of Their Medical Care. The New England Journal of Medicine, 336:1150-1156. Authors and study from Johns Hopkins Hospital, Internal Medicine inpatient service.RCT design. Patients with bedside presentations reported doctors spent more time with them, reported slightly better quality of care. Lower education level associated with more complaints of doctors using jargon.

Mooradian, N.L., Caruso, J.W., Kane, G.C. (2001). Increasing Time Faculty Spend at the Bedside During Teaching Rounds. Academic Medicine, 76 (2):200.Essay from authors at Jefferson Medical College.Residents evaluated attendings by time on ward, gave feedback to PD (no names), increased incidence of teaching at the bedside from 30% to 70%.Points for successful rounds:

Obtain pt consent prior to rounds Ask residents/students to demonstrate PE findingsExplain to pt purpose of rounds Model professionalismIntroduce team Allow pt to stop sessionBe courteous Allow pt the last word/question

Ramani, S., Orlander, J. D., Strunin, L., & Barber, T. W. (2003). Whither Bedside Teaching? A Focus Group Study of Clinical Teachers. Academic Medicine, 78 (4):384-390. Author is from Boston University. Focus groups among faculty describe obstacles/solutions.

Specific BarriersTeacher Declining BT skill System Interruptions

Inexperience Short admissionsPerformance pressure Technology overloadLack of controlTough to engage whole team Patient Patient discomfort w/idea of BT

Not believing BT worthwhile Patient too ill (unstable)Belief BT is for residents to do Patient off ward

Patient misunderstanding lingoClimate Limited time Patient privacy

Lack of faculty training Uncooperative/angry patientLack of faculty rewardsLack of role models

Miscellaneous Crowded roomNo blackboard/X-ray view-boxCan't refer to textbookTeacher/learner hesitancy in discussing Differential DxFear of undermining house staffLearner fatigue

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Ramani, S., et al (2003). (con’t)Strategies to Increase/Improve BTPre-rounds Prepare goals for each session

Orient learners to those goals (PE, communication, professionalism)Orient patients to purpose of rounds

During rounds Establish safe environment ("I don't know" is OK)Respect learners (1° caregiver, challenge don't humiliate)Respect patients (humans, not specimens)Engage everyone in the roomInvolve the patientMatch teacher-learner goals

Post-rounds Debrief

Ramani, S. (2003). Twelve Tips to Improve Bedside Teaching. Medical Teacher, 25 (2):112-115. Source for model cited in handout.

Williams, K. N., Ramani, S., Fraser, B., & Orlander, J. D. (2008). Improving Bedside Teaching: Findings from a Focus Group Study of Learners. Academic Medicine, 83 (3):257-264. Authors from Boston University. Focus groups among residents describe obstacles/solutions.

Barrier StrategyPersonal Low initiative Institutional incentives

Low teacher/learner expectations Set explicit expectations/objectivesLow BT teaching skills Set good learning environment

Acknowledge learners needsPlan flexibility per workloadSelectively/efficiently integrate BT w/workSet teaching time limits

Low clinical knowledge/skills Faculty developmentReassure: EVERYONE has something to offer

Interpersonal Pt uncooperative Ask beforehandOrient pt to format/goalsInclude/inform pt

Lack of learner autonomy Respect learner-pt relationshipNegotiate level of autonomySupportive learning environmentShare teaching w/team members

Learner/pt fear of embarrassment As above (interpersonal category)

Environmental No time (workload/turnover rate) Team cap, add nonteaching serviceCompeting faculty duties Reduce themLow expectation/incentive to teach Set explicit expectation/objectives

Create incentivesLow recognition Create rewardsFocus on technology vice clin skill Faculty development, EBM on clinical skillInterruptions, excessive noise (no strategy offered)Lack of privacy/space in room (no strategy offered)

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Wright, M. S., Kern, M. M., Kolodner, S. K., Howard, D. D., & Brancati, M. M. (1998). Attributes of Excellent Attending Physician Role Models. The New England Journal of Medicine, 339:1986-1993.Authors from Johns Hopkins University, study examined four teaching hospitals. Residents identified excellent role models, those role models and other “control” teaching staff were queried via questionnaire regarding various attributes. Those attributes associated with being identified as an excellent role model included:

1. >25% of time spent teaching2. > 25hrs/week teaching or rounding while on an inpatient service3. Stressing importance of the doctor-patient relationship in one’s teaching4. Teaching psychosocial aspects of medicine5. Having served as a chief resident

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