Editor’s Note: A cornerstone of EM education is teaching in a high volume and often low resource setting. This environment is often most extreme at county EM programs. The “Straight Outta County” series will focus on educational techniques and innovations from the CORD County Programs Community of Practice. If you are faculty at a County Program and would like to submit a post, please email firstname.lastname@example.org
Is Bedside Teaching Dead?
Author: James Willis, MD (Assistant Program Director, Kings County Hospital, Brooklyn NY)
Editor: Jay Khadpe, MD (@flatbushEM, Assistant Program Director, Kings County Hospital, Brooklyn NY)
Bedside teaching is a concept and skill I feel is spoken about a lot these days but is not as prominent in medical education as it once was. William Osler, considered the Father of Modern medicine, was a large advocate of bedside teaching. He has said:
‘‘Take the student from the lecture room, take him from the amphitheater. Put him in the outpatient department, put him in the wards. No teaching should be done without a patient for a text, and the best is that taught by the patient himself.’’
This is a sentiment that we all inherently know and have experienced. There’s no better way to have a topic solidified than to take care of a patient with that disease process. There is even literature that shows student, educator and even patient satisfaction can be improved with bedside teaching. It helps bring knowledge home for the learner, helps the educator witness mistakes or areas of improvement and the patient feels more involved with their care when the “presentation” occurs in front of them.
But in the age of EMR, ED over crowding, patient satisfaction scores and work hour regulations it’s getting harder and harder to bring medical education to the bedside. Now add that you are in a County hospital with understaffing, ridiculous wait times and an incredibly sick and underserved population it becomes near impossible.
The concept of bedside teaching has become more often thought about as physician training that occurs in the presence of patients rather than literally teaching at the bedside. I am not sure this is good enough. The following post will go over some tips/suggestions to help become a better bedside teacher even in the chaotic county ED. The teaching points are largely inspired from an article in Academic Emergency Medicine written by Drs. Aideen and Gisondi titled Bedside Teaching in the Emergency Department.
Plan teaching sessions before your shifts. We all know we will be seeing a chest pain, abdominal pain, and shortness of breath patient during a shift. Plan a 1-2 point discussion based on a concept or disease that ties into these complaints. This can be easily brought to the bedside to demonstrate a skill, a physical exam finding or procedure such as ultrasound without taking up a lot of time.
Know Your Team:
At the beginning of the day make introductions and identify the roles of your team. Education level and expectations are very different for a graduating resident to a first day third year medical student. Knowing these goals and roles of your learners can make for a very satisfying and educational experience.
This is at times the most difficult concept. In a busy county ED, there never seems to be enough time for this type of education. Here are some ways to bridge that gap:
- Performing education at the bedside of a stable or waiting patient with a non-emergent issue will make the patient feel their physician has spent more time with them.
- When spending extra time with complicated patients bring the learners with you. They can view shared decision making or other discussions with patients that you may already be spending time doing. Resuscitation can be another time that is ripe for opportunity for bedside teaching. These patients are too unstable for us to leave them so why not educate while standing there. Merely by discussing your thought process out loud can be invaluable to learners.
Start Low … Go Slow:
Make sure you don’t go overboard; patient care and efficiency should not be sacrificed. Focus on 2-3 topics initially and slowly increase your teaching library. Limit the amount of time you are spending at the bedside and preface this with your learners beforehand. Ensure they know the goals of the session, save questions for afterwards, and define the learning objectives.
Be A Role Model:
One of the easiest ways to perform bedside teaching can be to bring the learner to the patient while you perform an interview, assessment or close a visit. You can emulate ideal behavior and demonstrate humanistic behavior.
Regardless of the type of teaching, being a role model is important. Ask the patient for permission and introduce the learner, close the session by involving the patient and ask if the patient has any questions.
Beware the Socratic method, aka pimping, of using questions or quizzing to direct discussion. It can be humiliating and detrimental to a learner relationship. If you do use this method at the bedside try to target learners who are not the primary caregiver in order to preserve the patient’s confidence in them.
Take 30 seconds to summarize the learning points of the session, give feedback to the learners, and open yourself to feedback. Always make sure to ask for questions or if there is not time, offer to discuss questions in the future.
Incorporating bedside teaching in the ED can be challenging. By utilizing these techniques, we can bring EM education back to the bedside. Both learners and patients will appreciate more face time and you don’t have to sacrifice time or efficiency. Try these techniques out and let us know how they worked for you. Leave us a comment or if you have additional tips on incorporating bedside teaching during a busy shift, please share below.
For more on bedside teaching in the ED, checkout these additional resources: