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A CASE FOR

BEDSIDE TEACHING

Prof . B. K. Nair
Ms. J. Coughlan
Prof. M J. Hensley
Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle
What is it?
 Patients like it
 Students like it
 Students need it
 Students want more of it
 Teachers like it and can not do it
 What should we do about it?

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


This talk
 Why revisit these papers
 Learner, patient and teacher
perspective
 Should we improve and increase BST
 Where from here?

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


“To study the phenomena of disease
without books is to sail an uncharted
sea. Whilst to study books without
patients is not to go to sea at all.”

(Osler 1849-1919)

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Medical Education

 Promote acquisition of life long active


learning habits
 Introduce PBL
 Shift from lectures to small group and
independent learning

(World Conference on Medical Education Edinburgh 1988)

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


“Bedside teaching should be integrated in
the teacher-student and patient-student
relationship”

(WHO - Brussels 1992)

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


What is bedside teaching?
 Any where where there is a patient
 Ambulatory clinic
 Operating theatre
 Home
 Wards

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Advantages
 Additional info
 Observe student skills
 Role modeling
 Humanize care
 Active learning
 Activated patient
 Improved understanding of patient

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Challenges for educators
 56% diagnoses from history
 80% from history and physical
 Learners distracted by technology
 Teachers are overwhelmed by service
and administration
 What should we do?

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


What happened ?
 75% of time in 1960s
 16% in 1978
 Less in 2005?

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Most common ‘barriers’
 Patient discomfort
 Lack of confidentiality
 Hard to locate
 Learners reluctant
 Time consuming
 Teacher uncomfortable

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


LEARNER

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


AIM

 To investigate impressions and opinions


about bedside teaching among

• students, interns and residents


• patients.

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


STUDY DESIGN

 Student Survey (handed out /mailed out)

 Intern & Resident Survey (Mailed out)

 Patient Survey (administered)

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


STUDY DESIGN

Group: Response
Experience:

Up to Yr 4
Yr 5 Students
Up to Yr 5
Interns

Residents 1 year post grad

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SURVEY DESIGN:
Student, Intern and Resident Survey

Self administered questionnaires:


• Age
• sex
• status
• Best location for Case Presentations

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SURVEY DESIGN
Student, Intern and Resident Survey

 Is BST an effective way to teach?


 Did you get enough BST?

– professional skills generally?

– specific professional skills?

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SPECIFIC PROFESSIONAL SKILLS

 Communication Skills
 Obtaining Medical Histories
 Conducting Physical Examinations
 Applying Basic Science Knowledge
 Record Keeping
 Evidence-based Medicine
 Self-Directed Learning
 Time Management

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


TARGET POPULATION

Student Intern Resident Total


(n) (n) (n) (n)

Male 26 22 23 71

Female 52 36 41 129

Total 78 58 64 200

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


RESPONSE RATES (%)

Student Intern Resident Total


n (%) n (%) n (%) n (%)

Male 13 (7) 16 (8) 7 (4) 36 (18)

Female 38 (19) 32 (16) 30 (15) 100 (50)


136
Total 51 (26) 48 (24) 37 (19) (68)

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SITE PREFERENCES:

80
70
60
50 Student
40 Intern
30 Resident
20 All
10
0
Bed C'dor Conf rm Combo Other

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


GENERAL PROFESSIONAL SKILLS

100

80

60 Students
% Interns
40 Residents
20

0
Effective Enough

n=51 n=48 n=37 n=37 n=17 n=22


Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle
COMMUNICATION SKILLS

100
90
80
70
60 Student
% 50 Intern
40 Resident
30
20
10
0
Effective Enough

n=43 n=44 n=35 n=38 n=40 n=30

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


PHYSICAL EXAMINATION
100
90
80
70
60 Student
% 50 Intern
40 Resident
30
20
10
0
Effective Enough

n=51 n=48 n=36 n=18 n=26 n=29

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


BASIC SCIENCE
100
90
80
70
60 Student
% 50 Intern
40 Resident
30
20
10
0
Effective Enough
n=42 n=40 n=28 n=12 n=17 n=14

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SELF DIRECTED LEARNING

100
90
80
70
% 60 Student
50 Intern
40 Resident
30
20
10
0
Effective Enough
n=37 n=26 n=23 n=27 n=25 n=25

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


RECORD KEEPING
100
90
80
70
60 Student
% 50 Intern
40 Resident
30
20
10
0
Effective Enough
n=24 n=29 n=22 n=10 n=7 n=11

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


EVIDENCE-BASED MEDICINE

100
90
80
70
% 60 Student
50 Intern
40 Resident
30
20
10
0
Effective Enough
n=32 n=31 n=25 n=14 n=13 n=15

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


PATIENT

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SURVEY DESIGN
Patient Survey

 Number of days in hospital.


 Experienced BST? No. of times?
– understand your illness
– enjoy it
– feel anxious
– inappropriate discussion
– forewarning
– breach of confidentiality
– recommend to other patients

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


PATIENT CRITERIA

• competent in written and spoken English


• not cognitively impaired
• not too ill
• voluntary informed consent

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Results: (subjects)

Interviewed Had BST


n= 160 n=100 (63%)

Average Age 61.5 yrs 62.6 yrs


% Males 51 52
% Females 49 48
Average Stay 7.5 days 8.93 days

Frequency of BST 1 per 2.4 days

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Patient Responses
% % %
Yes No No
Resp

Understanding 68 32 0
Enjoy BST 77 17 6
Anxious 17 83 0
Inappropriate discussion 7 93 0
Forewarning 37 63 0
Breach of confidentiality 12 86 2
Recommend to other patients 84 11 5

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


TEACHER
 Students love it and do not get enough?
 Patients like it and gain from it
 Why not do it then?

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


AIM

 To investigate impressions and opinions


about bedside teaching among clinical
teachers

 BST Definition:
• All patient related teaching including
inpatients, outpatients, theatre & rooms.

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


STUDY DESIGN

 Self Administered questionnaire:

• coded to identify non-responders


• follow up mail out after 6 weeks
• data entered and analysed anonymously

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SURVEY DESIGN:

Three sections:
1 Respondent details
(time practicing medicine, specialty)

2 Opinions about BST


(general and specific professional skills)

3 Hindrances to BST

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


SPECIFIC PROFESSIONAL SKILLS

 Communication Skills
 Obtaining Medical Histories
 Conducting Physical Examinations
 Applying Basic Science Knowledge
 Record Keeping
 Evidence-based Medicine
 Self-Directed Learning
 Time Management

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Response Rate

Survey Recipients 152


Respondents 120
Response Rate 79%

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Respondents

<10 yrs 11-20 yrs >20yrs Total


(n) (n) (n) (n)

Medicine 5 58 32 65
Surgery 2 12 14 28
O&G 2 5 9 16
Paeds 0 3 5 8
Anaes/ICU 0 0 3 3
Total 9 48 63 120

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Case Presentation Site
Preferences

100
90
80
70
60
% 50 Teacher
Student
40
30
20
10
0
Combo Conference Bed Corridor

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Lack of Support
100
90
80
70
60
% 50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Noisy Ward
100
90
80
70
60
% 50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Own Understanding
100
90
80
70
60
% 50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Patient Anxiety
100
90
80
70
60
% 50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Patients not in bed
100
90
80
70
60
% 50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Student Basic Science
100
90
80
70
% 60
50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Student Clinical Skills
100
90
80
70
60
% 50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Time Constraints
100
90
80
70
60
% 50
40
30
20
10
0
No resp Never (Rarely) (Sometimes) (Often) Frequently

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Average Hindrance Scores

5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0

Understand
Not in Bed

Clin Skills

Basic Sci

Support
Pt Anxiety
Noise
Time

Own
Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle
Other Hindrances

 Group size over 4 or 5


 Limited patients with good clinical signs
 “Good” patients become exhausted
 Shorter length of stay
 Reduced bed numbers
 Emphasis on community care

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Other Hindrances (2)

 More work demands


 Low recognition of the role
 Outpatients not structured for BST
 Student availability
 Lack of privacy in crowded ward

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Other Hindrances (3)
 Interruptions from acute clinical problems

 Interruptions from bedside telephones

 Interruptions from visitors

 Lack of warning to patients on admission

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Comparison of % of Students and Teachers who agreed or
strongly agreed that BST is an effective way to develop
specific professional skills.

100 Students
90 Teachers
80
70
60
% 50
40
30
20
10
0

Time Mx
History

Communicat

EBM

SDL

Record
Science
Physcial

Keep
Basic
Exam

ion

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Ideal model

 Ask ahead of time


 Introduce the team
 Brief overview and explain
 Avoid technical jargon
 Base teaching on the data on patient
 Genuine closure
 Return visit by a member to clarify

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Ideal model

 Focused teaching
 Diagnose patient
 Diagnose learner
 Targeted teaching
 Role modeling
 Feed back

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Ideal model
 Group dynamics
 Limit time and goals for the session
 Include everyone in teaching and
feedback

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Advantages of bed side teaching
 Patient found it therapeutic
 Humanize medicine
 “Gomers/ social admissions” and
“acopia” are people too

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Conclusions
 Patients like it
 Students like it
 Students need it
 Teachers like it and can not do it
 What should we do about it?

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


“The facts are locked up in the patient - to
the patient, therefore, he must go”

Abraham Flexner, 1910

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Bedside teaching
 Where from here?
 How do we engage clinicians?
 This is our core business!
 Should do more qualitative reserach

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


HISTORY TAKING

100
90
80
70
60 Students
% 50 Interns
40 Residents
30
20
10
0
Effective Enough

n=45 n=47 n=35 n=35 n=34 n=30

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Effectiveness and quantity of BST in
Medical History Taking. (%)

Enough BST Total

Effective Yes No No Response

Agree 69 18 6 93

Disagree 2 2 0 4

Neither 2 0 1 3

Total 73 20 7 100

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Effectiveness and quantity of BST in
the application of basic science knowledge. (%)

Enough BST teaching in the application of basic


science knowledge

Effective Yes No No Response Total

Agree 28 47 5 80

Disagree 2 2 2 6

Neither 2 10 2 14

Total 32 59 9 100

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


BST is an effective way to teach
professional skills:

100
90
80
70
60
%
50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Effectiveness and quantity of BST in
Record Keeping. (%)

Enough BST

Effective Yes No No Response Total

Agree 14 38 2 54

Disagree 3 11 2 15

Neither 4 23 3 30

Total 21 72 7 100

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Effectiveness and quantity of BST in
Evidence-based Medicine. (%)

Enough BST

Enough Yes No No Response Total

Agree 23 38 4 64

Disagree 2 7 1 10

Neither 6 15 5 26

Total 31 59 10 100

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Effectiveness and quantity of BST in
Self Directed Learning (%)

Enough BST

Effective Yes No No Response Total

Agree 35 19 8 62

Disagree 9 5 2 17

Neither 11 8 3 22

Total 56 32 13 100

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Role modelling is an important
part of BST
100

80

60
%

40

20

0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


BASIC SCIENCE
100

80

60
%
40

20

0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


EVIDENCE-BASED MEDICINE

100
90
80
70
60
% 50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


HISTORY TAKING

100
90
80
70
% 60
50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


PHYSICAL EXAM
100
90
80
70
% 60
50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


RECORD KEEPING
100
90
80
70
% 60
50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Self Directed Learning
100
90
80
70
% 60
50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Time Management
100
90
80
70
% 60
50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


BST makes patients anxious

100
90
80
70
60
% 50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


Patients like to be a part of BST
90
80
70
60
50
%
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle


COMMUNICATION
100
90
80
70
60
% 50
40
30
20
10
0
St Agree Neither St Disagree

Discipline of Medicine, Faculty of Medicine & Health Sciences, University of Newcastle

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