#11 Bedside Teaching 

February 22, 2022 | By Era Kryzhanovskaya

With Dr Suba Ramani

Summary

Join Molly, Era, and Dr Subha Ramani to discuss best practices for bedside teaching.  We help you move past Res-Attending and embrace effective bedside teaching!  You’ll learn to effectively prepare, lead, and debrief rounds with patients and learners.

Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME!

Credits

• Producers/hosts: Era Kryzhanovskaya MD / Molly Heublein MD
• Show Notes/Cover Art/Infographic: Andrew DeLaat
• Editor:  Clair Morgan of Nodderly (audio)
• Guest: Subha Ramani MBBS, MPH, PhD, FAMEE

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner/ Best piece of advice
• Picks of the Week
• Kashlak case 1
• Barriers to Bedside teaching 
• Effective bedside teaching
• Feedback on your teaching
• Kashlak case 2
• Tips for teaching the physical exam
• Take home points
• Outro

Bedside Teaching Pearls 

1. Have pocket-sized goals for clinical teaching, focus on a single teaching pearl for each patient. 
2. In the effective teaching triad: everyone comes away learning something – The Learner, Teacher, and Patient. 
3. Be flexible to teach on the fly and be able to adapt to various learning environments 
4. Establish a Safe and Positive learning environment first

Bedside Teaching Show Notes

Definition:

Bedside teaching is where the patient is present, and most importantly engaged as a partner in the process.  

Effective teaching is when everyone learns something, including all parts of the triad: the learner, the attending, and the patient. 

2 Types of Bedside Rounds: 

Teaching Rounds: Primarily for teaching, make sure to orient the patient to the patient to the purpose and goals,  for the aid of our future medical providers.  Usually involves more preparation ahead of time of teaching goals.

Work/Business rounds: Focused on patient care, let the patient know we are all thinking carefully on the patient’s best care.  

3 Main Barriers to Bedside Teaching Success 

Identifying and moving past barriers may allow more effective bedside teaching.

Culture-Driven: Finding the balance of work and teaching is very important and needs modification as a whole. 

Faculty Driven: Many faculty are unsure about their own skills (communication, exam, history taking) and believe that they might not have much to offer to the learner.  They may be in the mode of “res-attending”.

Learner Driven: Learners are often overwhelmed with tasks to complete that they may not feel they have the time to be taught. 

(Ray and Ganguli 2009)

Effective Approaches to Bedside Teaching: 

• Identify and try to move past barriers to bedside education
• Have pocket sized pearls to teach on each patient, avoid trying to cover too much
• Attendings should set one achievable goal for each day regarding teaching your learners.  “Today I want to engage all my learners”, “today I want to ask questions that promote clinical reasoning”, “today I want my senior resident to take the role of teacher and I will observe.”
• Establish a safe and positive learning climate ahead of time 
• key first step is preparation; familiarize yourself with the clinical curriculum and find out about the developmental level of the learners’ clinical skills
• Establish learning objectives- what are the goals to address in the room? (Ray and Ganguli 2009)
• Communicate the process to the patient including the goals, potential outcomes, and timeline.  Make sure to introduce all members of the team.  Don’t forget basic manners- ask the patient how they are doing.  Be sure to maintain focus on patient and not the computer in the room.
• Appreciate that there will be uncertainty and ambiguity, you cannot know everything.  Look at the team as a shared brain
• Focus on the “why” questions – over the “what” questions- in a non-threatening way
  • Why do you think this?
  • Why did you add this to your differential etc? 
• clearly focus on observing the trainee’s interaction with the patient–this allows teachers to evaluate trainees’ specific skills, attitudes, and knowledge at the bedside.  at the end of the teaching session there should be a feedback conversation to review what was taught. (Ray and Ganguli 2009)
• Make it clear that everyone has an equal contribution to the conversation (Ramani 2003)

BEDSIDE Approach: 

Briefing- set up the case ahead of time

Expectations- what are the learners specific goals?

Demonstration- model exam or communication skills

Specific Feedback

Inclusion of Microskills (Neher 1992).  The five microskills that make up the model are (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes. 

Debrief- questions? reflections?

Education- what next step resources to learn more?

From UC Riverside Bedside Teaching Module

Improving as a teacher

Learn from professional society resources such as SGIM Teach, Stanford Faculty Development Program

Get peer coaching, you can learn the most by having direct observation and feedback

EPAs around teaching may help us be aware of key skills by breaking down specifics that educators should be performing (Dam 2021)

Physical exam teaching:

Prepare ahead of time: Focus on your strengths, don’t feel intimidated by what you don’t know.   If you have some time, great to brush up on a specific exam and be open about that with the learner.  Model that we are all learners.   Choose a few specific things that you would like to demonstrate- it does not need to be a complete cardiac exam, choose a few pearls.

Decide if you are going to model, discuss and then have the learner perform the exam, then provide feedback; or will you have the learner demonstrate the exam first and you will observe.

Explain to the patient what you will be doing, have a running commentary of what you are looking for and what you find on exam.

Keep it focused and brief.  Plan to choose a limited number of patients, for example in an outpatient clinic half day see 1-2 patients with a resident.

Bring your teaching back to the “why”.  Highlight the clinical relevance of bedside exams.  Focus on a “reflective or hypothesis driven exam.” (Garibaldi 2021)  Tie your teaching back to pathophysiology or likelihood ratios to help learners see the practicality and retain the knowledge.  Reinforce cases that have similar findings or serial exams on the same patient to optimize skills (Mazzella, Rose-Jones 2018).

Debrief afterward- discuss any questions, feedback.  If there are things you don’t know, have a plan to look those up and discuss afterward.

If you are the learner trying to get more bedside exam oversight, ask your attending to help with specific goals

Take home points:

As a bedside teacher, enthusiasm, curiosity, compassion for the learners, and humility in our own skills as teachers is key

Engage the patient as an educator, as a partner

From Dr. Subha Ramani:

Best Advice:

• “I was told that I was looking at my learners through my own lens, attitude and through my skill set, not placing myself in my learners’ position. It resonated with me and took me on a different path”. 

Favorite Failure: 

• Using poor language with a resident learner which helped her reflect on her approach and use it as a learning experience, helped her change directions on her approach to teaching.

Links

1. Dr Ramani’s book recommendation: Talley and O’Connor ‘s Clinical Examination and  Sherlock Holmes – Clinicians are like detectives!
2. Era’s Pick of the Week: Yoga with Adriene – “The Queen of Pandemic Yoga”
3. Molly’s pick of the week: Gastro Obscura: Food history and short bios about bizarre food from all around the world. 
4. The Nocturnists Podcast

Goals

Listeners will become familiar with commonly used tools to integrate teaching into clinical care at the bedside. 

Learning objectives

After listening to this episode, listeners will be able to…

1. Describe the challenges in incorporating teaching into rounds or clinic experiences at the bedside and ways to overcome them
2. Recognize the opportunities to infuse bedside teaching into daily clinical routine 
3. List steps educators can take to improve their bedside teaching skills 

Disclosures

Dr. Ramani reports no relevant financial disclosures. The Curbsiders Teach team report no relevant financial disclosures. 

Citation

Ramani S, Heublein M, Kryzhanovskaya E. “#11 Bedside Teaching. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach February.  22, 2022.