Chapter 4
Bedside Teaching:
Recovering a Lost Art
Faculty Development Series
Madigan Healthcare System
Tacoma, Washington 98431
Bedside Teaching
Chapter Contents
Group Leader Checklist
Learner Needs and Resources Assessment (LNRA)
Attendance Sheet
Evaluation Form
Example Eight Steps
Handout
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 ___________
Check One
Name
Rank
Staff
Physician
Resident
Physician
Other
Professional
Discipline
Department or Mailing
Address
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 subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, 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 subject
The speaker gave adequate time for questions
Audiovisual / handout material added to the
presentation
Overall, 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
4
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:
•
•
•
•
•
How:
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
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 Handout
Blending Tradition, Humanity, Art & Science
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
“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 valuable
82% 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 Barriers
Barriers
Limited time
Attending inexperience or fear
Perceived patient discomfort
Overreliance on technology
Learner resistance
Recommendations
Be selective: not every patient
Don’t wait for a quorum
Be flexible
Faculty Development
Acknowledge self as “imperfect scholar”
Share the teaching
Encourage self-directed learning (SDL)
Ask permission
85% of patients prefer bedside rounds
Enhances patient and family centered care
Explain the importance of diagnostic skills
Incorporate the technology at the bedside
Be persistent
Include all learners
Never undermine the learner in front of
patient
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Take Learning to the Bedside
“The best teaching is taught by the patient himself.” ~ Sir William Osler
Prepare Objectives:
Brief Participants:
- Identify target learners
- Ask patient and explain event
- Determine teaching objective
(e.g. interviewing, physical
exam, interacting with family)
- Brief learners:
- Research topic as needed
- Discuss expectations
- Assign roles
The
Teaching
Cycle
- Clarify objectives
- Review ground rules
Debrief:
Clinical Experience:
- Ask learners for their
observations
- Explain
- Demonstrate
- Provide feedback
- Learner experiences
- Encourage self-directed
learning
- Assess
Small Group Teaching: The Basics
Learning Environment:
Low pressure
Stimulate discussion and doubt
Teach from the middle
Encourage self directed learning
Engage the learners / Share teaching
Think out loud
Effective Feedback Principles (SOME TLC):
Specific
Timely
Objective
Limited
Modifiable behaviors
Constructive
Expected
(Frequent)
Ask
Tell / Teach
Ask / Act
Provide Effective Feedback:
What did you do well? What questions or challenges did you have?
I observed… Then give a few general teaching points.
What will you do differently next time? Develop an action plan.
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Improving Bedside Teaching
Breaking Down OUR Barriers
Task #1
Bedside Teaching where I work
Obstacles
Task #3
Solutions
1)
1)
2)
2)
3)
3)
4)
4)
5)
5)
6)
6)
7)
7)
8)
8)
9)
9)
10)
10)
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Bedside Teaching
Task #2 – Road Maps OR Focused Teaching – 15 minutes
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.
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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Bedside Teaching
Reference model #1
The 12 Step Model
B
E
F
O
R
E
D
U
R
I
N
G
(adapted from Ramani, et al, 2003)
1) Prepare goals for the session
a. Use the curriculum
b. Meet the learners at their level
2) Draw a road map ***
a. Medical system to be covered
b. Skills or aspects to be taught
c. Observation vs. demonstration
d. Define which patients and how long
3) Orient learners ***
a. Objectives, expectations, ground rules
b. Assign roles (presenters, examiners, jargon police, timekeeper, etc.)
c. Set limits (no coverage of highly sensitive issues, etc.)
4) Introduction
a. Introduce whole team and road map to patient
b. Note primary goal is teaching
5) Interaction – Role model professional behavior for the learners
6) Observation – Step out of the limelight, support learner as primary caregiver
7) Instruction – Challenge the learners intellectually, don’t humiliate them
“DO’s”
Gentle corrections
Keep team all engaged
Admit knowledge limits
Learn from your students
Teach professionalism
Teach hands-on skills
Teach observation skills
Use teachable moments
“DON’Ts”
One upmanship
“What am I thinking?”
Ask juniors after seniors
Long didactics
8) Summarization – Recap for learners and the patient
A
F
T
E
R
9) Feedback – From learners, what went well and/or not well
10) Debrief
a. Time for questions/clarifications
b. Assign further reading/research
c. Discuss sensitive areas
11) Reflect
12) Prepare for next time
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Bedside Teaching
Reference Model #2
The 3 Domains Model (adapted from Janicik, et al, 2003)
Attend to Patient Comfort
1)
2)
3)
4)
5)
6)
7)
Ask the patient’s permission in advance
Introduce everyone on the team
Start with a brief overview from the primary caregiver (learner)
Give explanations without using medical jargon
Base the teaching points on that patient
Use a genuine, encouraging closure statement
Return later to check for and resolve misunderstandings
Focused Teaching
1) Diagnose the patient
2) Diagnose the learner
3) Provide targeted teaching ***
a. Role model professional behavior, communication
b. Physical exam or procedural skills
c. Teach general concepts
d. Give feedback (patient can also give feedback)
4) Debrief after the session
Group Dynamics ***
1) Limit the time and goals for the session
2) Include everyone in teaching and in feedback
3) Assign roles to everyone
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Supporting References and Resources
Bedside 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:
Debriefing
Clinical
Encounter
Preparation
Working
knowledge
Experience
Explanation
Cycle
Cycle
Briefing
Preparation
for next time
Explication
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 Exam
Communication/Interpersonal skills
Focus on pt-centered care
Integrating 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
1) Knowledge is constructed,
not accumulated
2) Expertise depends on experience
with cases
3) Students learn when they
are involved
4) Learning is both a personal and
a social process
Corresponding Rec’s for Teaching
Begin with students’ conceptualization;
Use probing questions; encourage reflection
Focus discussions on the patient;
Teach at the bedside; compare/contrast cases
Provide challenge and support; stimulate interest;
Make rounds fun; encourage independent learning
Develop a learning community; provide orientation;
Leaven credibility with authenticity;
Know your learner
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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
Time constraint
Potential Solutions
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.
observe
Demonstrate advanced skills;
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
Boredom
Fear of embarrassment
Plan ahead, limit single-resident exam time
Set the tone before bedside rounds; Teach vice putting on the spot;
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 findings
Explain to pt purpose of rounds
Model professionalism
Introduce team
Allow pt to stop session
Be 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 Barriers
Teacher
Declining BT skill
Inexperience
Performance pressure
Lack of control
Tough to engage whole team
Not believing BT worthwhile
Belief BT is for residents to do
System
Interruptions
Short admissions
Technology overload
Patient
Patient discomfort w/idea of BT
Patient too ill (unstable)
Patient off ward
Patient misunderstanding lingo
Patient privacy
Uncooperative/angry patient
Climate
Limited time
Lack of faculty training
Lack of faculty rewards
Lack of role models
Miscellaneous
Crowded room
No blackboard/X-ray view-box
Can't refer to textbook
Teacher/learner hesitancy in discussing Differential Dx
Fear of undermining house staff
Learner fatigue
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Ramani, S., et al (2003). (con’t)
Strategies to Increase/Improve BT
Pre-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 room
Involve the patient
Match teacher-learner goals
Post-rounds
Debrief
Ramani, S. (2003). Twelve Tips to Improve Bedside Teaching. Medical Teacher, 25 (2):112115.
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):257264.
Authors from Boston University. Focus groups among residents describe obstacles/solutions.
Personal
Barrier
Low initiative
Low teacher/learner expectations
Low BT teaching skills
Strategy
Institutional incentives
Set explicit expectations/objectives
Set good learning environment
Acknowledge learners needs
Plan flexibility per workload
Selectively/efficiently integrate BT w/work
Set teaching time limits
Faculty development
Reassure: EVERYONE has something to offer
Low clinical knowledge/skills
Interpersonal Pt uncooperative
Ask beforehand
Orient pt to format/goals
Include/inform pt
Respect learner-pt relationship
Negotiate level of autonomy
Supportive learning environment
Share teaching w/team members
As above (interpersonal category)
Lack of learner autonomy
Learner/pt fear of embarrassment
Environmental No time (workload/turnover rate)
Competing faculty duties
Low expectation/incentive to teach
Low recognition
Focus on technology vice clin skill
Interruptions, excessive noise
Lack of privacy/space in room
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Team cap, add nonteaching service
Reduce them
Set explicit expectation/objectives
Create incentives
Create rewards
Faculty development, EBM on clinical skill
(no strategy offered)
(no strategy offered)
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 teaching
2. >25hrs/week teaching or rounding while on an inpatient service
3. Stressing importance of the doctor-patient relationship in one’s teaching
4. Teaching psychosocial aspects of medicine
5. Having served as a chief resident
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