Bedside teaching
Azim Mirzazadeh MD
Assistant Professor
Division of General Internal Medicine
Department of Medicine
Tehran University of Medical Sciences
Topics
Brief overview of:

The benefits and challenges of bedside
teaching

The strategies for improving teaching at
the bedside
There should be ‘‘no
teaching without the
patient for a text, and
the best teaching is
often that taught by the
patient
William Osler
1849-1919
Definition
 In modern times our definition of bedside teaching
(BST) includes any teaching done in the presence of
the patient, regardless of the setting
 Therefore, it may occur in ambulatory clinic, inpatient
ward or conference room
Current situation

Several surveys indicate that clinical teaching is moving
away from the patient’s bedside into conference rooms
and hallways
(Nair et al, 1997)
Current situation

It is dishearting to realize that the time allotted to BST
declined from 75% of teaching time 30 years ago to just
16% by 1978 and is certainly much lower now
(El-Baghir, 2002)

Estimates of time actually spent at the bedside vary from
15% to 25%
(Ramani et al, 2003)
Why the bedside teaching
is so important?
Benefits

Opportunity to:
• gather additional information from the patient
• directly observe students’ skills
• role model skills and attitudes
Humanizes care by involving patients
 Encourages the use of understandable
and non-judgmental language

Benefits (con.)

Active learning process in which adults learn
best

Patients feel activated and part of the
learning

Improves patients’ understanding of their
disease and the work-up
What’s the opinion of different
participants about BST?
Major participants
Faculty
Bedside
Teaching
trainees
patient
Faculty

88% of attendings preferred that cases NOT be
presented at the patient’s bedside
(Kroenke, et al. 1990)

47% of attending physicans who had practiced
less than 10 years favored presenting and
teaching away from the bedside
(Wang-Cheng, et al. 1989)
Faculty

Of all respondents (120), 95% agreed or strongly
agreed that BST is an effective way to teach
professional skills
(Nair, et al. 1998)
Trainees
96% of residents preferred that cases NOT be
presented at the patient’s bedside
 Respondents believed that only 30% of an
attending's rounding time should be spent at the
bedside

(Kroenke, et al. 1990)

Only 2% of housestaff and 4% of students felt
comfortable presenting cases at the bedside
(Wang-Cheng, et al. 1989)
Trainees

100% of the students, interns and residents
(N=136) believed bedside teaching was valuable

Once they experienced it, over half said they did
not receive enough of it
(Nair, et al. 1997)
Patients

85% of patients preferred to be present when their cases were
presented
(Wang-Cheng, et al. 1989)





68% found that it increased their understanding of their medical
problems
77% said they enjoyed it (only 17% did not)
83% said it did not make them anxious
85% said they do not think that bedside teaching breaches
confidentiality
84% said they would recommend bedside teaching to other
patients
(Nair et al. 1997)
Conclusion

We see that physicians have echoed some of our
same initial reactions to bedside teaching

when bedside teaching is actually studied,
patients and learners appreciate it and find it
effective
Conclusion
It is time we stopped blaming patients
and students for our own insecurities
at the bedside
Why the bedside teaching
is so sparingly used?
Barriers to Bedside Teaching

Teacher-related

Teaching climate–related

System-related

Patient-related

Miscellaneous
(Ramani et al. 2003)
Barriers to Bedside Teaching
Teacher-related

Declining bedside teaching skills

Inexperience with bedside teaching

Bedside aura

Lack of control

Difficulty in engaging all team members

Lack of motivated teachers

View held by some that bedside teaching should be done
by more junior educators such as residents
Barriers to Bedside Teaching
Teaching climate–related

Time constraints

Lack of faculty training in bedside skills

Lack of rewards for teaching

Lack of teaching role models in faculty’s own training
Barriers to Bedside Teaching
System-related

Interruptions (phone calls, visitors, pagers)

Short patient stays

Too much technology
Barriers to Bedside Teaching
Patient-related

Perceived patient discomfort

Ill patient

Absent patient

Patient misinterpretation of discussion

Patient privacy issues

Uncooperative/angry patient

Change in patient profile
Barriers to Bedside Teaching
Miscellaneous

Large crowd in small room

Noisy wards

No blackboard or x-ray view boxes for discussion

Inability to refer to textbook

Teacher and learner hesitation in discussing differential
diagnoses

Fear of undermining housestaff

Learner fatigue
Strategies for improving BST

Improving bedside teaching skills of faculty

Diminishing the aura of bedside teaching

Enhancing the value of teaching

Establishing a teaching ethic
(Ramani et al. 2003)
Model of Best BST Practices

Domain I. Attend to Patient’s Comfort

Domain II. Focused Teaching

Domain III. Group Dynamics
(JANICIK & FLETCHER, 2003)
Model of Best BST Practices
Attend to Patient’s Comfort
 Ask ahead of time
 Introduce everyone to the patient
 Brief overview from primary person caring for patient
 Explanations to patient throughout, avoid technical language
 Base teaching on data about that patient
 Genuine, encouraging closure
 Return visit by a team member to clarify misunderstandings
Model of Best BST Practices
Focused Teaching
 Microskills of teaching:
Diagnose the patient
Diagnose the learner
Observe
Question
Targeted teaching
Role model
Practice
Teach general concepts
Give feedback
Model of Best BST Practices
Group Dynamics
 Limit time and goals for the session
 Include everyone in teaching and feedback
Take home message

Bedside clinical teaching, an essential tool for learning, is
practised less frequently nowadays

Students, trainees and teachers fully support this activity

There are different types of barriers to bedside teaching

We need to be more familiar with these barriers in our
institutions and find the solutions to increase the role of
BST
Suggested readings
 Ramani S. “Twelve tips to improve bedside teaching.” 2003.
Med Teach. 25(2): 112-115. (provided)
 Janicik RW,
Fletcher KE. “Teaching at the bedside: a new
model.” Med Teach. 2003. 25(2): 127-130.
 Ramani S., et al. “Whither Bedside Teaching? A Focus-group
Study of Clinical Teachers. Acad Med. 2 0 0 3. 78 (4)
Medicine is learned
by the bedside and
not in the classroom
William Osler
1849-1919
Thank you