The Greek root for the word “clinician” is “klinikos”( the bed). Clinician is so called because he/she works at the patient’s bedside. It stands to logic that clinical teaching has to be at the bedside. All senior clinicians know that clinical skills have deteriorated over the past several decades and agree that bed-side teaching of medical students and house-staff is essential. Medical students look forward to clinical teaching with hands-on experience. After all, that is what they expected and entered medical education for. Patients know that the society needs future physicians trained in clinical skills. Patients have repeatedly stated that being part of clinical teaching is valuable and important to them. Most seem to enjoy the experience. If so, what is the problem?
Efforts are under way to improve the situation. Some medical schools have started bed-side teaching starting in the first year and continuing through the entire 4 years. Supervised physical examination followed by immediate feedback is part of the requirement for students in their senior year in some schools. But some basic problems remain such as inadequate number of clinical role-models as teachers, time constraints on clinical teachers (between their RVU’s and teaching schedule) and the related issue of who pays for teaching-time.
I have always felt most comfortable teaching at the bedside by modeling my behavior. It was challenging to balance the needs and expectations of the child and the parent and the needs and expectations of the learners. If we are to re-invigorate bed-side teaching, we need to know what the expectations, fears and hopes of patients are and what they like and do not like about bed-side teaching. Some will not like it at all, and we have to be sensitive even if they do not voice their objection.
Incidentally, one of the most intriguing things I have done during bedside rounds is to let the mother do the teaching, when appropriate. This was most effective when caring for children with uncommon conditions and syndromes. The mothers knew more than me anyway. They enjoyed teaching. The students learnt not only medicine but also what it is to live with a child suffering from a complicated chronic disease. I learnt a whole lot in the process!
There are a few studies on the patients’ perspective on bed-side interactions. The one I wish to comment on is by Drs. Fletcher, Furney and Stern (Patients speak: what's really important about bedside interactions with physician teams. Teaching and Learning in Medicine 19: 120-127, 2007). This is a study based on a theory of qualitative research, called Grounded Theory in which a model is created based on analysis of actual data. Selected patients were interviewed to voice their opinions on the perceived benefits and concerns related to bed-side rounds. These audio-taped interviews were analyzed to generate a model in which items of importance to patients were categorized. The final model contained two major components: 1.Patient-team interaction and 2.Team characteristics.
Category 1 (Patient – team interactions) included items related to information exchange, evidence of caring, involvement in teaching, knowing the team and bedside manner. Category 2 (Team characteristics) included items related to team attributes and team collaboration and communication. Patients had lots to say about all these areas – not surprisingly. As pointed out by Walker Percy, “if you listen, patients will tell you not only what is wrong with them, but also with you”.
You may wish to read the article for details. But the items I looked for relates to the “bed-side manner”. What do patients think it is made of? Here are some ideas: “showing interest in patient via nonverbal cues, establishing personal connection, acknowledging patient’s affect” and “non patronizing” attitude, using humor (Caution: It has to be proper and appropriate), using language they can understand and not allowing more than one person examining at the same time”.
Most patients were positive about their experience. But I was surprised that many patients did not feel they contributed much to the learning of students.
All these observations are intuitive to expert clinicians. But it is good to have science behind it so we can teach the junior faculty and students. It is interesting that the Bill and Melinda Gates Foundation is spending millions of dollars to study the characteristics of good teachers in public schools. We need to know what makes for a good teacher in a medical school at the bedside.
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