Williams, Keith N. MD, MSME, EdM; Ramani, Subha MBBS, MMEd, MPH; Fraser, Bruce PhD; Orlander, Jay D. MD, MPH
There is a general uneasiness both in the minds of the public and also in the practicing physician, that future specialists in internal medicine will become mostly reliant on laboratory, computerized, nonpersonal techniques of management, and the patient as a human being with emotional and psychological aspects will be forgotten. If such physicians are to come into being, it must be due to the kind of training and environment to which they are exposed in their years in medical school. - —L.H. Nahum
Bedside teaching, clinical teaching done in the presence of a patient, has been a fundamental component of medical training in the United States since the institution of modern methods of instruction in the late 19th century. Although few data exist regarding the effectiveness of bedside teaching, many medical educators espouse its value in training physicians.1–17 It seems logical to assume that clinical skills related to physician–patient communication, physical examination, clinical reasoning, and professionalism are better learned at the bedside than in a classroom. Nevertheless, the proportion of clinical educational time devoted to bedside teaching has ranged from 8% to 19% since the 1960s.18–23 Although medical educators have speculated on the reasons for this paucity, few studies have examined the issue systematically. Existing studies have had a limited scope or have explored bedside teaching only from the perspective of teachers.24–28 Although numerous guidelines advocating specific bedside teaching strategies have been published, it is unclear whether the perspectives of learners influenced their development.29–42
Learners are likely to have unique and valuable perspectives on bedside teaching; any effort to increase or improve bedside teaching should consider their views. Our objectives were to explore learners’ attitudes toward bedside teaching, perceptions of barriers, and strategies to increase its frequency and effectiveness. We included learners at different stages of training to assess whether experience influenced perspective.
With the exception of the principal investigator (K.W.), all coinvestigators had qualitative research experience before the conduct of this study, and one (B.F.) taught a graduate course on qualitative research. We conducted six focus group discussions between June 2004 and February 2005 with students from the Boston University School of Medicine and residents from the Boston University Residency Program in Internal Medicine. All prospective participants received an e-mail letter of invitation. Participation was voluntary and confidential, and verbal consent was obtained from all participants. We audiotaped discussions and transcribed them verbatim. The institutional review board of the Boston University Medical Center approved the research protocol.
We sought varied perspectives by recruiting participants at different stages of training. Groups one and two consisted of fourth-year students. Groups three and five consisted of “first-year” internal medicine (IM) residents, and groups four and six of consisted of “second-year” IM residents; by definition, the former had completed one year of postgraduate study, and the latter had completed two.
We defined bedside teaching as clinical teaching in the presence of a patient. We constructed open-ended questions to explore learners’ experiences and opinions regarding bedside teaching. We asked whether they learned from bedside teaching and, if so, what they had learned. We asked about the quality and quantity of bedside teaching they received. Finally, we solicited their views on barriers to bedside teaching and suggestions on strategies to increase its frequency and effectiveness. The interviewer (K.W.) pursued relevant themes and sought clarification or elaboration as required. Participants had ample opportunity to express unsolicited opinions.
Focus group discussions were 60 to 90 minutes in duration. The principal investigator (K.W.) conducted all interviews and, using standard qualitative methods, coded the transcripts.43 We grouped coded passages into major categories and identified prominent themes that emerged. We also identified contrasting responses across the experience levels of participants.
Thirty-three students and residents participated in one of six focus group discussions (Table 1). All residents had attended medical school in the United States or Canada. Coded passages generated several categories: value of bedside teaching, quantity and quality of bedside teaching, barriers to bedside teaching, and strategies to increase and improve bedside teaching. Differences between students’ and residents’ views were apparent and reflected differences in their roles. When applicable, we have noted the level of learner. Statements represent the views of learners and not the authors.
Value of bedside teaching
Learners believed bedside teaching is valuable, if not essential, for learning skills relating to physician–patient communication, physical examination, clinical reasoning, and professionalism (List 1). They reported that observing the resident or attending physician interact with patients is often instructive. Learners indicated that patients also benefit from bedside teaching encounters, and they emphasized that discussions of topics not directly related to patient care are more appropriately taught elsewhere.
It's very powerful if you see the example on an actual person, and especially if you know more about their story, their background, you're more likely to take something away from that experience, whether it be some kernel of knowledge about a disease or a certain way of interacting with patients. (Fourth-year medical student)
Quantity and quality of bedside teaching
Learners stated that bedside teaching is underutilized and that there are missed opportunities for bedside teaching. They reported that the quantity and quality of bedside teaching vary greatly among faculty and, for students, between clerkships. Students noted the most bedside teaching during their IM clerkships, but even there, quantity and quality vary.
We do [bedside teaching] rarely because I feel like when it happens it stands out so much. (Second-year IM resident)
Barriers to bedside teaching
Viewing bedside teaching as the interplay of patient, teacher, and learner in the context of the learning environment, barriers were classified as personal, interpersonal, or environmental (Table 2). Personal barriers are factors attributable to individuals, whereas interpersonal barriers represent aspects of the relationship between at least two individuals. Environmental barriers denote contextual factors that influence bedside teaching. The learning environment includes cultural aspects of the learning institution as well as structural and functional aspects of the patient-care environment. Several overarching themes emerged from the data: lack of respect for the patient; time constraints; learner autonomy; faculty attitude, knowledge, and skill; and overreliance on technology.
Lack of respect for the patient.
Learners expressed concern for patients’ welfare and recognized that their own education is secondary to patient care. Bedside discussion of sensitive issues, such as substance abuse, mental health, and sexuality-related topics, could embarrass the patient and result in the elicitation of inaccurate information. Discussion of diagnostic possibilities could cause undue alarm, particularly conversations about fatal diseases such as cancer. Bedside deliberation of management plans could lead patients to lose confidence in the medical team if they witnessed disagreements. Learners attested that patients are rarely asked permission or oriented to bedside teaching. Most concerning to learners are situations in which the patient is marginalized during a bedside discussion, as manifested by a clinician's failure to seek patient input, explain medical terminology, or answer questions.
I've seen attendings or residents exclude the patient when they're bedside teaching, and patients find that really offensive because it's their body, it's their story, and they're marginalized while they're being used for teaching, whereas if the patient's included then it's great for everybody and it's a really effective learning tool. (First-year IM resident)
Most learners believed that time constraints significantly limit bedside teaching. Contributing to this perception are a high resident workload and the observation that attendings often maintain significant ambulatory, administrative, or research responsibilities during their ward service, thus reducing time for learner interaction and bedside teaching. Learners preferred to avoid extended teaching encounters when overwhelmed by workload or fatigue.
You duck out and you're not involved in the actual teaching at the bedside because you need the computer and the phone in the hallway to get things done so that things are happening earlier in the day and you're not discharging someone at six in the afternoon. (First-year IM resident)
Interestingly, some learners questioned why bedside teaching should take more time than that required for teaching in other settings. Such speculation led them to conclude that there is not so much a lack of time for bedside teaching, but for all teaching.
Theoretically, bedside teaching shouldn't take any longer. What we're actually saying is there's not enough time for teaching in general, rather than for bedside teaching. (First-year IM resident)
Advanced residents expressed concern that bedside teaching compromises the relationship between learner and patient. They feared that bedside demonstration of deficiencies causes patients to lose confidence in the learner as clinician, or in the advanced resident as team leader. They also feared that their attendings would usurp their authority to manage the team. Although many learners voiced discomfort at admitting “I don't know” to their patients, some accepted the necessity, if not inevitability, of making such an admission. Some believed that lack of harmonious team dynamics contributes to these difficulties.
It is uncomfortable when you're the resident and the patient knows that you're the one that's there all the time and somebody's going through this lengthy teaching episode with you, because I feel they want to be comforted by the fact that you know something, which you do, but there's that line where it can be uncomfortable. (First-year IM resident)
Ironically, some residents believed that attendings sometimes allow excessive autonomy. In such circumstances, all teaching suffers, not just that performed at the bedside.
We crave autonomy, but it's a balance. I'm at the point now where I don't want as much autonomy, I actually want to interact more with my attendings. I had an attending this past month who gave me too much autonomy. It was fun, it was easier, but I didn't learn much. (Second-year IM resident)
Faculty attitudes, knowledge, and skill.
Learners believed that all attendings have something to teach at the bedside. There was speculation that the reluctance of attendings to engage in bedside teaching derives more from lack of teaching skill than lack of clinical competence.
I definitely ran into some people where I'd ask them questions and I could tell that I was making them uncomfortable, even though they had lots to offer me. That was what was really strange; they didn't realize that I'm asking at such a basic level that they have lots to teach me. (Fourth-year medical student)
Overreliance on technology.
Given the ever-increasing technological options for diagnosis and treatment, some learners questioned the role and importance of proficiency in bedside diagnostic skills if further testing is done regardless of clinical impression. This loss of faith in traditional skills led to speculation about whether efforts to learn them are futile.
So much of medicine now with radiology studies and blood tests is so algorithm driven that a lot of this other stuff doesn't matter anymore. I know what the plan's going to be before I see the patient. A lot of bedside teaching is gone away because of that. (First-year IM resident)
One intern used to call the CT scanner the “doughnut of truth.” It's kind of revealing. It's like saying that you don't need to lay your hands on the patient, just plop them down on the thing. (Second-year IM resident)
However, many learners believed that, in spite of technology, patients still expect dialogue with and examination by their physicians and are disappointed and indignant when clinical interactions are inadequate. Some learners desired international medical experiences where they could obtain traditional clinical teaching in the absence of the influence of technology.
I don't think we'll ever get away from the physical exam. Even if you don't have to listen to their lungs and learn anything, the patients feel so much more of a connection to you when you do. It's more than just learning the physical exam. It's learning patient interaction, too. (First-year IM resident)
Strategies to increase and improve bedside teaching
Learners provided many insightful recommendations to increase and improve bedside teaching (Table 2). Strategies addressing the barrier themes noted previously are discussed below.
Orient and include the patient.
Although patients were rarely described as uncooperative, learners emphasized the need to orient patients and request permission before teaching. Explaining the purpose of a bedside teaching encounter and requesting permission to observe or examine were identified as important signs of respect that foster trust and cooperation.
The most important thing is being able to develop a rapport with your patients, and making them feel like you're not forcing something on them, where it's a comfortable environment. If an attending or resident has the ability to establish a relationship with the patient that's reasonable, you can get a lot more out of that situation because the patient is more willing to participate and the students will feel more comfortable in that setting, too. (Fourth-year medical student)
Learners believed that inclusion of patients permits clarification of historical facts and validation of exam findings. It allows the medical team to educate patients about their conditions and options for care. They felt that establishing rapport with patients could alleviate concerns regarding discussion of sensitive topics and prevent misunderstandings or alarm with regard to discussion of diagnostic possibilities or management plans. Patients might also have the satisfaction of contributing to the education of future physicians.
The attending did a good job of making the patient feel we cared about her. He set a good example of making her feel like a whole person and not a specimen, in the end reassuring her about her findings: “This isn't new, this is something that we've already known you have, and what I'm talking about here isn't anything for you to worry about, and it's consistent with the diagnosis you have and nothing's changed.” I thought that was a good closure to the teaching. (Fourth-year medical student)
Address time constraints through flexibility, selectivity, and integration.
Although many time-related factors are beyond their control, learners provided several suggestions to address the effect of time constraints. Faculty accommodation of the call schedule and resident workload was considered paramount. Learners stated that it is senseless to engage in prolonged postcall teaching rounds when the team is too fatigued and distracted to engage in a meaningful learning experience. Faculty teaching at the bedside should be selective and limited in duration. Paradoxically, some residents suggested that faculty participate regularly in work rounds; they recognized the efficiency of combining work and learning, especially when it obviates the need to round later with the attending. Residents advocated a decrease in the number of patients they manage on the teaching ward. Considering the amount of clerical work associated with each patient, even slight reductions in census numbers would increase the time available for teaching.
[It] is very important to prioritize, to pick one or two pearls on the patients that you're interested in and emphasize that, because we're not going to remember more than that, and we usually don't have time for more than that. (First-year IM resident)
Learners emphasized the value of having attendings available on the ward on a consistent basis. Attending time on the ward should be “protected” from competing responsibilities.
It really helps when the focus of that person's day is to take care of patients and to do teaching … it makes a big difference … rather than someone who's got their hands in so many things, their mind might be in as many places. (Fourth-year medical student)
Provide learners with reassurance, reinforce their autonomy, and incorporate them into the teaching process.
To alleviate their anxiety at the bedside, learners believed that simple reassurance by the attending physician is often sufficient. They advocated the establishment of a positive learning environment in which acknowledgement of deficiencies and errors is accepted as an inevitable, if not essential, aspect of the learning process. In this context, bedside questioning is seen as a Socratic exercise in learning, not as “pimping” with an intent to demoralize or cause embarrassment. Some believed that harmonious team dynamics facilitate acceptance of one's own limitations.
If teachers can set the tone and what the expectations are and say that “it is okay to make mistakes, we all make mistakes, but the great doctors are the ones who take those mistakes and use them to improve themselves,” that's the best way to learn in that stressful environment. (Second-year IM resident)
Some residents suggested that autonomy, although important for professional growth, could sometimes be counterproductive in its effect on opportunities for learning, because autonomy often correlates inversely with attending participation. They recognized the need to balance their roles as managers and learners, although it is often difficult to negotiate the appropriate level of autonomy with attendings. They believed that distributing teaching responsibility to all team members and creating a collaborative learning environment could minimize compromise of the professional relationship between learner and patient.
One solution is to equalize the teaching on the team. Just because you're ahead of someone else, like the attending's above you or you're above the intern, doesn't mean you're going to know more about every topic than the medical student. (First-year IM resident)
Develop faculty attitudes, knowledge, and skill for bedside teaching.
Learners suggested faculty and resident training to develop effective bedside teaching skills. Such training could alleviate the anxiety related to bedside teaching content, such as physical examination skills. They advocated a variety of bedside teaching strategies, including assessment of learners’ needs, role modeling, selective and explicit instruction, learner evaluation and feedback, and distribution of teaching responsibility. Legitimate institutional incentives for proficient teaching should be available.
Everything counts the minute you walk into the patient's room. Everything you do is being watched, whether it's something you say, or it's the way you approach the patient, the way you sit by the bed, or just the way you're ignoring what the patient's saying. Teachers should be very sensitive to that issue alone. It's not just the verbal aspect of teaching. (Second-year IM resident)
Advocate evidence-based physical diagnosis.
Learners believed that the indifference of the medical establishment towards physical diagnosis skills derives from lack of emphasis in training, and they suggested that faculty and resident training initiatives could improve these skills. They encouraged participation in international medical experiences in which technology does not play a central role in the diagnosis and treatment of illness.
Some things in physical exam are actually useful. There's some literature on the prognosis implied in a certain physical exam finding. Us[e] that to say, “these things are important and it can actually guide the management.” (Second-year IM resident)
Table 2 lists these and additional strategies to increase and improve bedside teaching.
Contrasting student and resident perspectives
Residents’ beliefs, such as the desire for autonomy in patient care and for a collaborative learning environment, were more pragmatic than those of students. This pragmatism stemmed from two major differences between students and residents. First, residents viewed bedside teaching, and teaching in general, from the vantage points of both learner and teacher. Second, their views were influenced by work responsibilities and a desire to have a reasonable quality of life, even during training. Teaching initiatives that fail to recognize these differences are often unsuccessful.
Students focused on the physical diagnosis aspects of bedside teaching to a greater degree than did residents. First-year residents were overwhelmed with the responsibilities of daily work, and thus found bedside teaching, and perhaps all teaching, to be another demand on their limited time, and they reported that they often felt too distracted to learn. In the second year of residency and beyond, residents recognized that their role as a team leader allowed them opportunities to influence the frequency and form of bedside teaching rounds.
There were definitely times where somebody said the word[s] “attending rounds” and I was ready to shoot myself. I was completely disinterested and in fact angry that that was what somebody wanted to do when I had a million other things, and it was only going to keep me in the hospital really late. Some people just don't have any understanding of what's going on around them. (First-year IM resident)
The resident's attitude permeates the team, so you can create a local environment of eagerness and motivation to learn. (Second-year IM resident)
Our learners confirmed faculty beliefs that bedside teaching is valuable for learning essential clinical skills, such as those related to physician–patient communication, physical examination, clinical reasoning, and professionalism.27,28 In the absence of studies validating the effectiveness of bedside teaching, this affirmation by learners is important. Their recognition that they learn by observing more experienced clinicians interact with patients supports the use of role modeling, an implicit form of teaching, at the bedside. Although they had concerns for the patient and their own psychological well-being during the bedside teaching encounter, they identified strategies to avoid potential harm. We are encouraged, given the learners’ beliefs that patient inclusion and faculty development could rapidly enhance the frequency and effectiveness of bedside teaching for the benefit of all.
One of our most striking findings is the recognition by learners that, for the patients and themselves, sensitivity in the interpersonal aspects of bedside teaching is paramount. A poorly executed bedside teaching encounter disrespects patients and compromises learners in their roles as clinicians and managers, thus diminishing their perceived autonomy. Fear of the consequences of poor interpersonal communication during bedside teaching is prevalent. Simple strategies to avoid these pitfalls, such as orienting patients to the process, and explicit acknowledgment of human limitations, can be easily incorporated by faculty.
Although lack of time is frequently described as a major barrier to bedside teaching, some learners believed that this is more perception than reality. In fact, the data suggest that when time is limited, all teaching is compromised, not just bedside teaching. More importantly, learners suggested that properly executed bedside teaching could be integrated within typical clinical activities, such as work rounds, allowing efficient time use.
Autonomy was a major concern for residents. They avoid teaching situations that might jeopardize their role as manager and the students’ or first-year residents’ role as caregiver. A collaborative approach to teaching helps to preserve the integrity of their semiautonomous roles. Learners found it difficult to admit “I don't know” during a bedside teaching encounter. Reassurance by attendings and the establishment of a positive learning environment and harmonious team dynamics can alleviate these concerns.
Learners speculated that faculty might be reluctant to teach at the bedside because of a lack of teaching skills rather than a lack of clinical competence. In their opinion, the belief that technology has supplanted the medical history and physical examination undermines bedside teaching. Faculty development could address both of these issues.
The differences in the perspectives of students and residents regarding bedside teaching are provocative. One could predict both the tremendous appeal of bedside teaching to students as they learn the skills of clinical medicine and the pragmatism of first-year residents inundated with work. However, second-year residents’ expectation for a more collaborative approach to teaching is somewhat unexpected and compelling. This expectation stemmed from a need for autonomy as they embraced their newfound leadership role. Their desire for a collaborative approach has profound implications: if given the opportunity to influence the timing, content, and process of bedside teaching, residents could have a key role in promoting the regular occurrence of such teaching.
Our findings complement previous literature reports regarding learners’ perspectives on bedside teaching. In a study by Nair et al,26 learners were found to believe that bedside teaching is a “valuable way to develop professional skills.” More than 90% of the learners believed that bedside teaching is effective for learning communication, history-taking, and physical examination skills. Between 41% and 65% stated that they do not receive sufficient bedside teaching. Our findings also complement the views of teachers. In another study by Nair et al,27 95% of teachers agreed that bedside teaching is an effective way to develop professional skills, and more than 80% believed that it is effective for learning communication, history-taking, and physical examination skills. Comparison with a study by Ramani et al28 reveals a striking similarity between the perspectives of teachers and the views of our learners; teachers concurred with the five overarching themes we describe in this paper, including learner autonomy, as suggested by a “fear of undermining housestaff.” They also suggested strategies to increase and improve bedside teaching that are remarkably consistent with those of our learners, such as orienting the patient, establishing a positive learning environment, and treating the learner as primary caregiver for the patient. The suggestions of our learners are compatible with the bedside teaching recommendations of various educators.29–42 The “model of best bedside teaching practices” by Janicik and Fletcher,42 which describes three domains of effective bedside teaching skills (attending to patient comfort, focused teaching, and group dynamics), addresses several of the important findings in our study.
Bedside teaching, rather than being an antiquated mode of clinical instruction from a pretechnological era, is consistent with modern education theory. Specifically, it is consistent with the experiential learning principles of the progressive movement that began in medical education during the late 19th century, as well as with the principles of adult learning as defined by Malcolm Knowles.44,45 Most striking, however, is the compatibility of bedside teaching with the modern theory of situated cognition, or contextual learning, which states that the learning of knowledge is inherently dependent on the context in which it is learned; that is, “knowledge is situated, being in part a product of the activity, context, and culture in which it is developed and used.”46 William Osler4 was aware of the advantages of contextual learning: “In what may be called the natural method of teaching, the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end.” Our learners were aware of this “contextual” advantage, as demonstrated by their views regarding the value of bedside teaching. One may logically ask, how else is a student of medicine to become a professional, let alone learn the appropriate manner of speaking with, touching, and comforting a patient, if not in the context of the bedside teaching encounter?
This study has several limitations. We recruited students from only one school of medicine, and residents from only one specialty at a single academic medical center. Our study explored learners’ opinions about bedside teaching but did not address whether increasing or improving bedside teaching would lead to better learning outcomes or enhanced patient care. Although there is always the potential for interviewer bias to influence the views of participants during focus group discussions, we attempted to reduce this possibility by limiting the interviewer's dialogue to questions and clarifications and by avoiding expression of opinion. We also avoided asking whether learners “liked” bedside teaching; we focused instead on questions concerning value, barriers, and strategies.
Future research should determine whether faculty development directed at improving bedside clinical and teaching skills could enhance bedside teaching and should focus on a variety of learner outcomes, including knowledge retention, skill proficiency, and professionalism. Meanwhile, the results of this study support ongoing efforts to promote faculty development in teaching and to facilitate an institutional culture and environment conducive to the regular occurrence of bedside teaching.
We believe clinical education that incorporates substantial bedside teaching is an effective approach to fulfilling the public interest of training intelligent, skilled, and compassionate clinicians. Including the patient, collaborating with learners, developing faculty skills, and promoting a supportive institutional culture can redress a variety of barriers to bedside teaching. In the end, “no books, no tapes, no audio-visual aids, no seminars, no avant-garde philosophy will ever be substitutes for the discipline of the bedside medicine—the one-to-one situation where tradition, humanity, art and science are blended.”6
This research was supported in part by the HRSA Faculty Development Training Grant # D55HP00215.
Preliminary results of this research were presented orally at the 2005 New England SGIM Regional Meeting, Hanover, New Hampshire, and by poster at the 2005 SGIM Annual Meeting, New Orleans, Louisiana, and the 2005 AAMC Annual Meeting, Boston, Massachusetts.