Bedside clinical teaching for medical
students at UNC
Peadar G Noone, MD FCCP FRCPI
UNC Chapel Hill.
AOE UNC Chapel Hill
Background
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For generations, clinical bedside teaching was the basis of
medical school education (think of the weighed down white coat
– hammers, ophthalmoscopes, tuning forks etc)
Started with the clinico-pathologic correlation science in the late
19th century (the Oslerian school)
UK / Irish medical school teaching (the “colonial” system) still
heavily bedside focused
Less so in the US: recent publications lament this decline
(though not everyone in agreement).
Outstanding clinical
teachers in history:
Cheyne
Graves
Stokes
Corrigan
Adams
Wilde
Osler
Verghese (Stanford)
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Noone background:
• Traditional medical school, 3 basic science years, 3
years of clinical training, heavily bedside focused
• Intern: small community hospital with very
charismatic clinician teacher at the helm
• Every ward round was a teaching round, every clinical
point, sign and laboratory value squeezed dry
• Post graduate examination in British Isles
(MRCPI/MRCP) still involves several bedside
components with real patients and patient data
• 2010: Invited back as extern examiner for the “Final
Med” exams at RCSI Dublin
Bare below the elbow, no tie, jewelry
Today:
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Abraham Verghese –NEJM article “Culture shock – patient as
icon, icon as patient”*
Spoke about the “tension” between traditional approaches (the
body as a text) versus the care of the “iPatient” (in the “bunker”)
http://stanfordmedicine25.stanford.edu/
Whose fault – us as teachers?
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Time, expectations, the encroachment of more exciting technologies,
computerized records
Do our students want anything different?
* NEJM 2008; 359: 2748-2751
Lets get back to
basics at UNC:
Inspect
Palpate
Percuss
Auscultate
Cerebrate
A pilot study of rotating bedside clinical tutorials
for medical students at UNC
Hypothesis: That med students want bedside clinical
teaching, and that data will support that
Aims:
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1.
2.
To study the feasibility of rotating clinical tutorials for clinical students
To gather data to assess the benefits of focused teaching in the context
of modern medical education
Preliminary data:
•Feedback over many years of clinical teaching on
rounds, enthusiastic generally, perhaps there is indeed a
“hunger” for this type of approach
•There is a literature supporting this from formal studies
•e.g. NEJM: Images in clinical medicine etc
Objectives: To teach
•History taking skills
•Clinical exam
•Presentation skills
•Clinical reasoning
•Professionalism
•Spin off benefits: Attending learn more about patients
problems
• Patient benefits of learning about their disease
Methods:
•Advertised via student forums, flyer and direct
conversations with students on the wards
•E-mail communication usually with first-come-firstserved sign up
•Once every two to three weeks.
•Strictly bedside, appropriate patient selection important
•One to two hours depending.
•Questionnaire formulated (based on the literature and
my instincts)
Results:
•Anonymous
•n=11 sessions
•N=31 students
•Stretched over several months
•Data analyzed with help of UNC student on work
experience (Melissa House).
•Data qualitative, showing simple outcomes of various
measures the students were asked to score
Conclusions:
•Generally the tutorials were well received
•Scored pretty well on most measures
•Consistent with what is in the popular press and formal
medical literature
•Did not ask for feedback from patients
•Did not follow up long term
Limitations:
•Time consuming: Students, teacher time (afternoon
formal teaching, MPH, research, organization and
communication)
•Student understanding of the principles (bedside? – you
mean in the room all that time?; how are we supposed to
do this? Are we just to turn up?)
•Patient availability and quiet time (its hard to get an
hour+ in a room undisturbed)
•Other (vasovagal episodes in two students not used to
spending that much time on their feet in the room)
ACKNOWLEDGEMENTS:
•The Academy of Educator Grant Mechanism
•Melissa House work study student
•UNC Med students
•The willing patients