Some Thoughts on Bedside Teaching
Article Outline
There is general agreement throughout academic medicine that bedside teaching and its concomitant honing of clinical skills have been eroded significantly by changes in the financial environment of academic medical centers, as well as by changes in residency work hours. The large-volume clinical care system that is currently in place in academic hospitals occurs at the expense of time for teaching medical students and residents. Medical education in the third year of medical school has become much more classroom/seminar oriented rather than hands-on bedside teaching. A variety of surveys involving medical students demonstrate that students still perceive hands-on bedside teaching as one of the most valuable components of their medical education.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 Patients also view bedside teaching in a positive manner.4, 9, 10
Those of us involved in teaching medical students (undergraduate medical education) and residents (postgraduate medical education) have observed the problems involved in guaranteeing adequate hands-on clinical training during the third and fourth year of the medical curriculum. Duty-hour regulations imposed by the Accreditation Council for Graduate Medical Education on resident work efforts have had a definite negative impact on medical student perceptions of resident teaching.13
Bedside teaching involves the instructing physician interacting with a patient at the bedside to elicit the patient's history, demonstrate key features of the physical examination, and discuss the best approach to diagnosis and therapy for the patient. Bedside teaching was first mentioned in the 13th century by Geilielmus, a physician who taught diagnosis and therapy at the bedside.14 The original Hippocratic oath enjoins the physician to teach the craft to younger colleagues. Osler, the founder of our modern clinical medical education system, emphasized bedside interactions among the patient, the teacher, and the student. In fact, Osler requested that the epitaph on his grave should note only that he taught medical students at the bedside!
Thus, we have a serious conundrum in the 21st century: it is universally agreed by students, faculty, and patients that bedside teaching is important. Moreover, it is quite clear that skills are inadequately learned by students and residents when they receive insufficient training at the bedside. Finally, the quantity of bedside teaching, and hence, clinical bedside skills, have progressively deteriorated over the last 30 years.14
What can be done to remedy this serious problem? Clinical educators are stressed to the maximum because of reduced reimbursement rates for patient care. In the past, when more generous reimbursement rates existed, clinicians were happy, even proud, to donate their time and effort to educate medical students in clinical pursuits. The economic necessities of today have severely curtailed the ability of both private practitioners and academic clinician-educators to provide quality bedside teaching. What are we to do?
Faculty educators throughout the country have experienced this dilemma in recent years, and they have tried valiantly to preserve bedside teaching time by utilizing a significant portion of dollars from a variety of sources to support the teaching mission. Nevertheless, it is still widely felt among clinician-educators that we are still not providing adequate instruction in bedside teaching. Other measures aimed at improving student access to bedside teaching involve curriculum reform such as we have experienced at the University of Arizona during the last 2 years. Our new reformed curriculum, named Arizona Med, has a built-in emphasis on bedside teaching starting in the first year and continuing throughout the 4-year curriculum. It is believed that the development of bedside teaching “societies” created for this new curriculum will help to correct what has been considered a serious deficiency in medical education in recent years. Other medical schools, for example, University of California, San Francisco, have instituted similar variations of this “societies” program with openly expressed satisfaction on the part of students and faculty.
Other potential innovations that could be employed in the future to improve bedside teaching include: 1) addition of simulation techniques simultaneous with bedside clinical experiences, for example, the Harvey cardiovascular simulator; 2) requirement for all students of an in-depth subinternship in a specific area of endeavor, for example, medicine, surgery, pediatrics, etc; 3) successful completion by students of a number of computerized patient scenarios followed by appropriate questioning of the student concerning various aspects of the case viewed; 4) supervised, hands-on experience as a required part of surgical and obstetrics-gynecology rotations; 5) performance by all senior students of a faculty-observed history and physical examination of a patient in the inpatient or outpatient setting, followed by immediate faculty feedback to the student. Finally, it will be important for faculty educators to design a research protocol to measure the effectiveness of the above-described educational interventions with respect to improved student bedside clinical skills. Indeed, only by monitoring clearly delineated outcome measures will we know whether our educational innovations have made any difference in the clinical abilities of our graduates.
As always, I'd be interested in hearing your comments on this important topic. Feel free to send me an e-mail or post a comment on our blog, http://amjmed.blogspot.com.
References
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Funding: None.
Conflict of Interest: None.
Authorship: The author is solely responsible for writing this manuscript.
PII: S0002-9343(08)01068-1
doi:10.1016/j.amjmed.2008.10.024
© 2009 Published by Elsevier Inc.
