Ramani, Subha MD, MPH; Orlander, Jay D. MD, MPH; Strunin, Lee PhD; Barber, Thomas W. MD
Observe, record, tabulate, communicate. Use your five senses. Learn to see, learn to hear, learn to feel, learn to smell, and know by practice alone you can become expert. Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But see first.
This quote from William Osler1 reflects the importance of clinical learning at the patient's bedside. Eminent clinician–teachers2,3,4 have described many benefits of bedside teaching. Demonstrating communication skills and physical examination findings, teaching humanistic aspects of clinical medicine, and role modeling professional behaviors are some essential elements of education for good patient care that cannot be effectively accomplished in a classroom.
Although bedside teaching is considered to be a valuable teaching tool in clinical medicine, several surveys indicate that clinical teaching is moving away from the patient's bedside into conference rooms and hallways.5,6 Estimates of time actually spent at the bedside vary from 15% to 25%.5,6 The reasons for this decline are not completely clear. Several barriers to bedside teaching have been cited,3,7,8,9 mostly in the form of essays and commentaries. These essays also discuss good bedside teaching strategies,2,3,10,11,12,13,14,15,16,17,18,19 many proposed by respected bedside educators. It is possible that many clinical faculty are either unaware of these methods or are uncomfortable applying them at the bedside. It is also possible that changes in the health care environment have created additional barriers that limit time spent by teachers at the bedside.
To increase effective bedside teaching, barriers need to be better defined and methods to minimize these barriers need to be identified. In this study, our objectives were to identify a list of barriers that prevent clinical teachers from going to the bedside and to identify strategies that could potentially increase the frequency of bedside teaching, while making sessions mutually beneficial for teachers and students.
We conducted a total of four focus-group discussions during May 1998. Participants for all four groups were recruited from the Boston University School of Medicine faculty based at either of its major teaching affiliates, Boston Medical Center or Boston VA Medical Center. The faculty were general internists and subspecialists. Our goal was to select information-rich participants who would represent broad and varied perspectives on bedside teaching.
All prospective participants received a letter of invitation outlining the purpose of the study. The letter also mentioned that the interviews would be audiotaped for their content but that confidentiality would be maintained. A verbal consent to the audiotaping was obtained from all final participants. The protocol was approved by the Institutional Review Board at Boston Medical Center.
Group 1 (n = 6) consisted of PGY-4 chief residents, who had finished their residencies and were responsible for a significant amount of student and housestaff teaching. Group 2 (n = 6) consisted of medical residency program directors, all of whom were practicing general internists who also attended on the inpatient medical wards. All program directors and medical chief residents attended the meetings. Group 3 (n = 6) consisted of a convenience sample of “skilled” bedside teachers. These teachers were selected from a list of good bedside teachers generated by polling housestaff. Group 4 (n = 5) was a convenience sample chosen from the remaining department of medicine faculty who attend on the medical inpatient service. For Groups 3 and 4, our target was to obtain five to seven participants per group. Due to anticipated scheduling problems and time constraints, we contacted ten to 12 faculty for each of the latter two groups. None of the faculty invited refused the invitation, but availability for the interviews was limited by scheduling conflicts.
We developed open-ended questions to explore experiences, opinions, behaviors, values, and attitudes of the participants. The interviewer followed up on participants' responses, pursued themes, and sought clarification or elaboration as required. There were opportunities for the participants to express unsolicited opinions and recount their clinical experiences. The following is a sample of the questions asked during the interview:
▪ Are there any experiences related to bedside teaching during your training days that may have influenced you?
▪ How can you make the bedside teaching experience effective and satisfying for both teachers and learners?
▪ Can you name and define obstacles that prevent teachers from teaching at the bedside? Are there ways to overcome these barriers?
There were four focus-group interview sessions lasting 60–90 minutes each. The same investigator (SR) conducted all interviews to ensure uniformity. The semi-structured interview was pilot tested on a group of six general internal medicine fellows. At the end of the pilot session, the fellows gave their feedback on the structure of the questions and identified areas that needed clarification. A second investigator (LS), who is a skilled qualitative researcher, observed the pilot group and the Group 1 interviews. These observed interviews served as training and feedback sessions for the interviewer. The pilot group served as a testing session only, and these data are not included.
The focus-group interviews were audiotaped and transcribed verbatim. The investigator also kept field notes to provide an overall perspective of the interviews.
The analysis strategy used has been termed “immersion and crystallization” in qualitative research literature.20,21 Immersion means that the researchers surround themselves with the data while carrying out the analysis to become sensitive to the tone, mood, range, and content of the attitudes expressed in the data. Crystallization refers to the researchers' gradual development and clarification of the important common themes that emerge from the data. Thus, analysis and interpretation take place concurrently.
The transcripts were read and participants' views on bedside teaching were identified. These units of data were marked and descriptive phrases or words were written in the margins of the transcripts, a process referred to as coding. Each data unit, reflecting a specific issue, was assigned a code. Issues that were conceptually different were given different labels. Code labels were consistent with terminology used by discussants in order to avoid introduction of subjective bias.
Two investigators (SR, JDO) coded each of the transcripts independently, applying as many codes as needed for each data segment. A third investigator (LS), trained in qualitative methods, reviewed the coded material to ensure inter-rater reliability. Ambiguities or disagreements in coding were resolved by discussion between the two coding investigators and the reviewing investigator.
For each general content area that emerged, codes were grouped into two major categories, barriers and strategies. Major and recurring themes were then identified. Finally codes, categories, and themes were compared and contrasted with literature reports.
The characteristics of the participants in the four groups are shown in Table 1.
We generated an extensive list of individual barriers that prevent our teachers from teaching at the bedside. We classified them into five subcategories relating to the teacher, the teaching environment, the educational system, the patient, and miscellaneous. The list of individual barriers by subcategory is shown in Table 2.
A thematic analysis of the transcripts revealed that our faculty also repeatedly discussed four concepts related to the individual barriers. These concepts did not fit clearly under any of the barrier subcategories because they overlapped two or more of the subcategories mentioned above. These concepts appeared to be more important to our focus groups than all the individual barriers they described. The focus groups believed that unless these fundamental problems were addressed clinical teaching could not return to the bedside. These concepts and sample quotes are discussed below.
Declining bedside teaching skills
All groups felt that bedside clinical skills were declining among teaching physicians. Lack of confidence in one's own clinical skills makes faculty uncomfortable teaching at the bedside. Moreover, the teaching environment does not emphasize faculty development along these lines.
There's too much fear amongst our colleagues about doing bedside teaching. They don't have those skills…. it's not something they've done since medical school and maybe didn't do much in medical school… unless you inculcate that, it's going to be difficult to expect our students and residents to approach bedside skills.
It's easy for the attendings to hide behind the blackboard and go over data…. too many attendings' clinical skills are not what they ought to be.
Aura of bedside teaching
Another important barrier the focus groups discussed was the performance pressure clinical teachers feel in the context of bedside teaching. Younger teachers hear about “master diagnosticians of old” who conducted superlative bedside rounds, a level they feel is impossible to achieve. This feeling compounds the preexisting fear of loss of control at the bedside, a control more readily achievable in a classroom while lecturing.
…bedside teaching has a certain aura …you feel it's got to be scintillating…there is this angst built up, … whatever you do it's not enough…God, someone help me with this…. I'm lost, I'm floundering.
Oh, my God! I don't know anything about this condition. I am going to make a fool of myself at the bedside.
Teaching not valued
All groups felt that teaching was not perceived to be valuable by the current academic system because it is less financially productive compared with clinical and research activities.
Unfortunately the way American society has evolved, success is equated with money… teaching does not generate any money
The skill and art of teaching are not recognized in academic medicine, it's taken for granted…it's assumed that you'll do it and becomes a burden on the teacher. The system really needs to value teaching.
Erosion of teaching ethic
One focus-group member from Group 3 lamented the absence of a teaching ethic in modern-day medicine. Although this affects all forms of teaching, he felt that bedside teaching, especially, had become a victim because it is one of the most hands-on teaching methods.
I come from a background where the icons of academic medicine are the great teachers. Teaching is the pinnacle of academic life…. being a great diagnostician, to elicit a history no one else has elicited…great skills…equal to getting an NIH grant…that's the ethic one needs to create so that residents and students view that as a worthwhile goal.
Our focus groups also proposed specific strategies that could potentially overcome the four barrier concepts that the focus groups repeatedly discussed.
Improving bedside teaching skills of faculty
All of the focus groups stated that ongoing faculty training in clinical skills and teaching methods would be beneficial in promoting teaching at the bedside.
I would love to go on physical diagnosis rounds, cardiology rounds with a cardiologist…. learn the nuances I stopped learning when I was a junior resident…. of course, I'm dreaming…but if there were time in academic medicine to become nurtured and better developed.
Diminishing the aura of bedside teaching
The focus groups believed that all teachers, even more junior clinicians without proven expertise in clinical skills, had sufficient skills to offer to the learners. If teachers could be convinced of this fact, this might increase their comfort with teaching at the bedside.
You may not be an expert, but you still know a fair amount…. even if you are just a junior clinician.
You can't get everything, but you can get more than you did as a third-year student. You don't have to be this person doing this great exposée on teaching, as long as the person at the bedside is learning, you're probably doing well enough.
Enhancing the value of teaching
The focus-group participants felt that departments needed to appreciate teaching skills. One of the skilled teachers felt that clinical teaching was not something to be delegated to junior people and more senior faculty needed to teach clinical skills.
I suppose we should continue to tell people this is a very important thing. If you do a good history and a good physical, you are going to be a good doctor.
Why do we have fourth-year students teaching physical diagnosis to third-year students? Why is it that it's not the masters who are doing it?
Establishing a teaching ethic
Members of Group 3 (skilled bedside teachers) felt that inculcating a desire in learners to be at the bedside could perhaps be achieved by emphasizing its importance in clinical medicine, challenging learners to think clinically, fostering independent learning, and making even the so-called mundane diagnostic problems exciting. They believed that only global changes in attitude would increase the frequency and improve the quality of bedside teaching. They believed that help was needed from the system, namely the department of medicine and the medical school, to motivate and support faculty to this cause.
Probably the most important educational method we have… bedside teaching cannot be replaced with anything else…. We are dealing with an apprenticeship method of teaching…. We are the master, they are the apprentice and the only way to demonstrate how to chip a block of stone is to show how to chip it.
Teaching needs to be ratcheted up the priority ladder to the point that it happens more often…cutting back other clinical responsibilities when attending on the wards…I don't think they are cut back enough.
All groups had suggestions about strategies to overcome or minimize some individual barriers, particularly suggestions applicable to planned bedside teaching rounds. We classified these strategies as behaviors that could be carried out before, during, and after bedside encounters, and a detailed list is outlined in Table 3.
Focus-group participants also mentioned a few behaviors to be avoided at the bedside: (1) criticizing colleagues or learners; (2) using excessive medical jargon, which would confuse and alienate patients; (3) humiliating learners, which would destroy team morale; (4) launching into a didactic lecture, which would diminish audience participation; (5) arguing, which would impair patient respect and confidence; and (6) discussing differential diagnosis or prognosis without educating the patient.
Bedside teaching remains a highly regarded but underutilized approach in our institution. A diverse group of clinical teachers unanimously supported the goal of increased teaching at the patient's side, whilst many admitted to doing so infrequently. Most of the available reports on bedside teaching to date are essays, reviews, or editorials from individual authors, based on their personal opinions and experiences. The importance of our study lies in the fact that the barriers identified arise from the experiences and attitudes of a broad representation of clinical teachers, rather than from a single experienced academic educator. So, too, from this group come insights and strategies that may overcome said obstacles.
Our participants cited numerous content areas that may be optimally addressed at the bedside, echoing those mentioned in previous essays and literature reports.2,3 These include the teaching of medical ethics, demonstrating humanistic aspects of patient care, role-modeling professional behavior, and learning to see the patient as an individual. Some may consider these subtle but clearly vital aspects of medicine. Using bedside presentations, the teacher can obtain a more reliable picture of the patient and more time can be devoted to observing and demonstrating history taking and physical exam skills.2 Patients view the prolonged patient contact time as a positive experience in which they develop a better understanding of their illness.22
The group identified by our housestaff as skilled bedside teachers demonstrate that it is possible to conduct bedside rounds in a manner that is time efficient, reassuring to the patient, and educational for all. While these faculty validated many barriers previously described in literature,3,7,8,9, 23 they obviously were not daunted. In fact, several experienced clinician–teachers have made recommendations for bedside teaching strategies.2,3,10,11,12,13,14,15,16,17,18,19, 24 Still, it appears that, at least in our own institution, like others, little headway has been made in increasing the frequency of bedside teaching by the faculty at large.
Our thematic analysis of barriers identified an emphasis on four major areas. The first, declining bedside skills among clinical teachers, is related, we feel, to skills as well as to the confidence of the staff. The second, the aura (or myth) of the skill set necessary to be a successful bedside teacher, and the third, perceived lack of value placed on clinical teaching in the current health care environment, we label institutional. Last, the fourth, a perceived erosion of the teaching ethic in modern-day academic medicine, we would classify as attitudinal. While not all these themes are specific to bedside teaching, our participants believe that they particularly impact this method of clinical teaching.
What can be done to overcome such barriers? The strategies and specific behaviors suggested by our staff predominately address ways in which a bedside encounter can run more smoothly. By preparing oneself, the learners, and the patients in some fashion, one's sense of control increases and tension dissipates. Involving all parties and debriefing after the encounter allow for maximal clinical learning and could lead to improvement in the teaching process for subsequent encounters. These suggestions serve to address the first barrier theme related to the faculty's skill and confidence.
How can we address the institutional barrier of devalued teaching? Our institution has taken some small strides in this matter both before and after we collected these data. Annual teaching awards have been formalized and expanded to acknowledge residents, fellows, and hospital- and community-based faculty on an annual basis. In addition, a Special Recognition Teaching Award for long-term contributions to the teaching mission of the department was established. Awardees are acknowledged formally at an annual departmental event and written up in the department's newsletter, and engraved plaques outside our grand rounds venue serve as a constant reminder. Teaching efforts in several forums now earn credits toward the faculty incentive plan and, hence, provide a modicum of financial value. Support for specific staff to attend intensive faculty development training and on-site shorter programs for faculty at large have increased over the past few years. While not specifically targeting bedside teaching, these activities are encouraging.
Last, addressing the attitudinal barriers may prove more challenging. There were no firm ideas on how to get individuals to take the first step and have a full encounter at the patient's side. Our faculty reflected mostly on the importance of the task and the need to communicate such to fellow faculty and learners—a “teach and recruit by example” approach. Perhaps we need to bring together at a faculty level bedside teachers and non-bedside teachers in an attempt to dispel some of the aura relating to expertise in bedside teaching. We need to boost the confidence of our faculty in their own clinical skills. Given the broad range of skills and content that can be taught at the bedside, we believe the majority of faculty can provide good teaching at the bedside if they have more realistic expectations of themselves and such encounters. By avoiding patient-side teaching, faculty become part of the problem of the eroded teaching ethic.
A recent column by Kroenke,24 revisiting the topic of attending rounds, addressed some of these issues. Clinical teachers do not always have to be the star performers, instead they can learn to hang back, be silent, observe the drama, and be available like a midwife. He suggests that all clinical rounds need not be similar, and experimentation is encouraged. Clinical teachers need to show learners the way to life-long self-directed learning and provide gentle guidance rather than active spoon-feeding much of the time. Once teachers understand these facts, the anxiety over performing at the bedside can be eased. We need to figure out how to get this message through to our faculty.
Attempting to understand a complicated process such as clinical bedside teaching is challenging. We chose the focus-group method for its various strengths. Focus-group interviews are an efficient way to collect data, capitalizing on communication between research participants to generate discussion. This method is particularly appropriate when the interviewer has a series of open-ended questions and wishes to encourage research participants to explore issues, generating further questions and pursuing the subjects' priorities. Focus-group literature recommends an ideal group size of four to eight people,21 and our groups stayed within this range. We were able to explore opinions and attitudes of our teachers without subjecting them to our biases. The group dynamics were excellent, and we were able to generate a large body of data because of interaction between participants.
This study has several limitations. The use of faculty from a single medical school from the department of medicine alone limits the generalizability of our findings. Although we used a variety of clinical teachers, our findings represent only the teachers' perspective and not that of housestaff or students. Our study focused mostly on the inpatient setting, while patient-side teaching in the ambulatory setting may have alternative issues.
This area is ripe for future research. Studies should target learners' attitudes towards bedside teaching, faculty training programs aimed at increasing and improving this form of clinical teaching, and the impact of these teaching methods on students and housestaff. Research that can effectively demonstrate and measure the value of bedside teaching would be invaluable.
Written guidelines on teaching strategies alone are not likely to increase the frequency or improve the quality of bedside teaching. Department-wide efforts and support from faculty in leadership positions are required. Medical schools should reward clinical teachers for their efforts in order to encourage ongoing excellence in teaching. Periodic faculty development in teaching methods as well as training in advanced clinical skills would improve the ability and confidence of teachers to teach these skills, thereby resulting in better teaching at the bedside.
All clinician–teachers have something to offer to less experienced trainees that will enhance patient care. Unless we go to the patient's bedside together, we cannot realize what and how much can be taught. We believe in reversing the trend and going back to the bedside so that all of us can learn from this valuable tool.