|Year : 2014 | Volume
| Issue : 2 | Page : 57-61
Bedside teaching: An indispensable model of patient-centred teaching in undergraduate medical education
Department of Paediatrics, Bayero University, Kano, Nigeria
|Date of Web Publication||6-Sep-2014|
Dr. Mustafa Asani
Department of Paediatrics, Faculty of Clinical Sciences, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
Bedside teaching remains the most effective way of imparting competency in clinical skills in undergraduate medical education but there has been a noticeable decline in the practice of bedside teaching worldwide. This paper aims to emphasise the importance of bedside teaching, highlights the possible barriers to effective bedside teaching and equip medical teachers with the effective ways of achieving the intended goals of bedside teaching by emphasising the techniques recommended by experts in the field of medical education. Developed countries have employed the use of clinical skill centres to cushion the effect of the decline in bedside teaching, but in resource-limited countries it remains the only viable option. The advantages of bedside teaching include; learning in context, impartation of clinical skills, nurturing and development of clinical reasoning. In addition, bedside teaching provides opportunity for role modelling, professional thinking, observation of communication skills, team work and integration of communication skills, clinical skills and ethical issues in the process of patient care. Several hindrances to effective bedside teaching have been identified. These include a large student: teacher ratio, crowded lectures, improper use of logbooks, lack of preparedness and interest, increasing administrative and research works among medical teachers. The strategies recommended by experts can be categorised into three; based on the timing as; before, during and after bedside teaching. These emphasise the need for adequate preparation, setting of clear objectives before teaching, active participation, gentle correction during teaching, feedback and discussion of sensitive issues away from the patient.
Keywords: Bedside teaching, teachers, undergraduate
|How to cite this article:|
Asani M. Bedside teaching: An indispensable model of patient-centred teaching in undergraduate medical education. Niger J Basic Clin Sci 2014;11:57-61
|How to cite this URL:|
Asani M. Bedside teaching: An indispensable model of patient-centred teaching in undergraduate medical education. Niger J Basic Clin Sci [serial online] 2014 [cited 2019 May 23];11:57-61. Available from: http://www.njbcs.net/text.asp?2014/11/2/57/140305
| Introduction|| |
The importance of bedside teaching in medical education was emphasised by the father of modern medicine, Sir William Osler. He is widely acknowledged with the following statements on bedside teaching "To study the phenomena of disease without books is to sail an uncharted sea, while to study without patients is not to go to sea at all" and "The student begins with the patient, continues with the patient and ends his studies with the patient, using books and lectures as tools as means to an end."  He is credited as the one that introduced bedside teaching to modern medicine.  Bedside teaching forms an integral part of undergraduate training in medical schools. Cox observed that some medical schools, especially, those with few resources and large number of patients teach skills without prior preparation of the medical instructors and the students.  He stated that teachers even in the same environment differ widely on the objectives of the teaching and the ultimate standards to be achieved. His position reflects the practice in some medical schools in less developed countries whose faculty have little or no formal training in medical education. Malu, an experienced medical teacher observed that bedside teaching continues to be the major method of teaching clinical skills in Nigeria, in the absence of clinical skills laboratories but that there has been a steady decline in the time spent teaching clinical skills at the bedside.  Reichsman et al. in 1964 stated that about 75% of the teaching was at the bedside but by 2009, it was estimated that only 17% was carried out at the bed side. , Local data are not available to draw conclusions but many medical teachers will agree that enough emphasis is not being placed on bedside teaching when compared with the number of hours spent in the classrooms for didactic lectures, seminars, tutorials and e-learning. Advanced countries have employed the use of clinical skills laboratories to solve the inadequacies of bedside teaching. Ahmed, however, cautioned that clinical skills laboratories should be used as an extra tool and not a replacement for bedside teaching. 
This paper aims to stress the importance of bedside teaching, highlights the possible barriers to effective bed side teaching and equips medical teachers with the effective ways of achieving the intended goals of bedside teaching by highlighting techniques recommended by experts in the field of medical education. In essence, it echoes the words credited to an anonymous university of Chicago professor who was reported to have said "I'm not here to teach you, I'm here to see that you learn". 
| Definition|| |
There are several definitions of bedside teaching. Simply put, it can be defined as teaching beside the bed.  Mosalanejade et al. defined bedside teaching as any kind of training in the presence of patient, regardless of the environment in which the training is conducted.  Stewart did not also limit bedside side teaching only to hospital setting, but included an office setting and long-term facility.  Gale and Gale defined it as when a clinician supervises a group of students at the patient's bedside to elicit a history or physical signs.  No matter its definition, the following clinical activities are what constitute a bedside teaching; presentation of new cases clerked by students, demonstration of physical signs, providing feedback to students, showing humane ways of sharing bad news, physicians' personal interaction with patients etc.
| Objectives and Benefits of Bedside Teaching|| |
A result-oriented teacher must have clearly defined objectives before any bedside teaching. The benefits of bedside teachings are due to its patient-centred approach, unlike other forms of teaching. The role of bedside teaching in the training of clinically competent doctors cannot be overemphasised. For instance, Ahmed stated that over 50% of the patient's problem can be diagnosed from the history alone and up to 75% after a thorough physical examination.  The advantages of bedside teaching include; learning in context (the symptoms and signs that are derived from a live patient), increased learners' motivation (learners' are excited to see, feel and hear the content of lecture notes, tutorials and seminars), clinical skills are impacted, clinical reasoning is nurtured and developed and transferable clinical skills are imbibed (skills attained in the palpation of an abdominal organ in a particular patient is useful in other patients with abdominal mass). In addition, bedside teaching provides opportunity for role modelling, professional thinking, observation of communication skills and teamwork and integration of communication skills, clinical skills and ethical issues in the process of patient care. ,,
| Barriers to Effective Bedside Teaching|| |
Despite the numerous advantages of bedside teaching highlighted in the preceding subsection, there are barriers to effective bedside teaching. These barriers are chiefly responsible for the decline in bedside teaching. Ahmed in his paper titled "Bedside teaching at the Cinderella status" listed many factors.  Some of these factors are worth mentioning because of their relevance to our resource-limited setting.
High student: teacher ratio: A large crowd of students around a patient is an uncomfortable sight not only to the patient, but to the medical teacher because many of the students will at best be passive learners. 
Absenteeism: The natural tendency is for the average medical student to spend hours in the library trying to understand the numerous lecture notes to the neglect of bedside learning. This learning style stems from the fact that many of them passed their past examinations through rote memorisation. This defective and inappropriate learning style can be addressed by proper orientation during the introductory clinical posting and proper use of log books with emphasis on developing the psychomotor and affective domains of learning. 
Lack of preparedness before bedside teaching: Many teachers in medical schools especially in resource-limited countries have no formal training in medical education. Several decades ago, Biehn observed that most teachers have a naïve hope of impact on their students' clinical knowledge and skills, as long as the teachers are experienced and have a continuing role in welfare of the students despite lack of formal prior training in medical education.  There should be rounds dedicated primarily for teaching (teaching rounds), distinct from the daily rounds on in-patients (business rounds).
Interest and motivation: The interest of medical teachers in this effective tool of attaining competency can be aroused through training of medical teachers. 
Increasing administrative and research duties: The demands of these responsibilities on the time of experienced medical teachers may create a barrier to bedside teaching if not properly managed.
Faulty teaching methods e.g. teaching by humiliation: Students feel humiliated when harshly criticised, if they respond wrongly to questions or carry out inadequate physical examination. 
Crowded lectures: The demands of transforming novice medical students into competent doctors require a large volume of knowledge. However, if not carefully handled, students may be tempted to lay undue emphasis on the cognitive domain at the expense of bedside teachings.
Improper use of log books: University regulations should reflect the realities of medical curriculum by laying emphasis on the attendance of clinical teachings and procedures as a prerequisite for summative or exit examinations.
Low emphasis on communication skills in curriculum: This domain of learning is best demonstrated by the bedside but if not assessed during examination may be neglected by both the students and teachers.
The barriers to effective bedside teaching will not be complete if one fails to mention the increasing number of nomadic clinical teachers who visit, teach, and consult in other medical facilities under the guise of visiting lecturerships, community services while neglecting their primary duty of training medical students. Most of these are due to economic reasons.
| Types of Patient-Based Teaching Methods|| |
It is important to note that bedside teaching is not the only patient-based teaching but what makes it outstanding is that it is patient-centred. Other types of patient- based teaching as described by Doshi and Brown  include.
Role-modelling: This is also called shadowing. This is a type of patient-based teaching, whereby a medical student observes his clinical teacher's approach to consultation, communication skills and treatment plans. This form of learning is ideal in a busy outpatient clinic and emergency room but it requires extreme motivation from the learner, and the clinical teacher must be a good example of acceptable professional worth emulating in all areas, lest the learner is misguided. 
The report-back model: The medical student fully clerks a patient alone but presents history, physical examination findings, and treatment plan to the medical teacher or resident. This approach may be relevant in situations of time constraints when the presentation cannot be made during the round but its major drawback is the lack of supervision during the act of physical examinations and verification of physical signs picked by the trainee.
Direct observation: As the name implies, in this approach, the trainee is observed by the teacher e.g. when counselling a newly diagnosed case of diabetes mellitus. After the period, the trainer gives feedback on the trainee's performance. This model is better reserved for learning skills such as communication skills.
Videotaped interviews: A clinical encounter such as physical examination of the central nervous system and interview involving the medical student and the patient is recorded after the patient has given consent. The video is then reviewed with the teacher either with the student alone or in the company of other students and feedback given.  The drawback of this approach is anxiety of the trainee during the video recording obviously because of self- consciousness. 
Case conference: In this approach, a case is presented to a group of professionals, which may cut across several departmental staff. 
| Strategies of Effective Bedside Teaching|| |
The importance of bedside teaching has stimulated a lot of interest in the field of medical education. Several strategies have been proposed by some experts in the field. ,,, Janicik and Fletcher developed a three-domain model, which was the outcome of a workshop with over 135 medical educators in attendance. The three- domains emphasised are (1) Attending to patient's comfort: Informing patient and asking for consent ahead of time (2) Focused teaching: Following clear objectives and providing adequate feedback and (3) Group dynamics: Engaging all the trainees by assigning them roles. There is the five-step model described by Neher  - Prepare, Brief, Teach, Reflect and Homework.
Gagne et al. highlighted nine events of instructions, which are very useful in structuring an effective bedside teaching.  These include: Stimulate the interest of the students, the trainees should be informed of the objectives of the teaching. The teacher should at this point stimulate the recall of background knowledge relevant to the bedside teaching. The teacher then proceeds to give the trainees a summary of the patient's history.
The teacher tells the trainees how to perform the task. He then performs the task and allow the trainees carry out the assigned task. Feedback is then given to the trainees on their performance, debriefing follows. The teacher will then suggest activities to build on the newly learnt task.
Ramani's 12 tips to improve bedside teaching contains a simplified outline of some recommended strategies by experts in medical education.  It is also pertinent to note that these 12 tips are actually in three stages; Before the bedside teaching, during the bedside teaching and after the bedside teaching.
Tip 1: Preparation: If the goals of bedside teaching are to be met, adequate preparation is essential. The teacher should know the level of knowledge of the students. Adequate preparations can be made by observing senior colleagues and reading relevant books on history and physical examination of the clinical task to be taught.
Tip 2: Blue print: The teacher should state the objectives of the bedside teaching clearly e.g. Body system to be taught.
Tip 3: Inform the trainees about the goals and objectives of the task. The trainees can be assigned specific roles to perform during the teaching. This is to encourage active participation.  Tips 1, 2, and 3 are done before the bedside teaching.
Tip 4: Introduction of team members and teacher to the patient. The teacher informs the patient the purpose of the encounter. This is a vital ethical requirement in addition it prevents the patient's personalisation of all the clinical diagnoses mentioned at the bedside. 
Tip 5: Role modelling: The teacher can use the encounter as an opportunity to answer questions raised by the patient. The trainees will learn from such physician-patient interactions. 
Tip 6: Teacher steps out of the centre stage: Allow the trainee take history, talk to the patient and examine. Such observations will alert the teacher to the areas of deficiency thus enabling planning for future interaction. 
Tip 7: Ask edifying question without humiliating the trainees. Mistakes should be corrected tactfully. Competition should be discouraged among the trainees; they should be encouraged to improve their personal performance, not necessarily outshining others.
Tip 8: Provide a summary of lessons learnt to the trainees. The patients should be reassured that not all medical conditions mentioned in the encounter are applicable to them. ,
Tips 4-8 are carried out during the bedside teaching, while 9-12 are done outside the ward e.g. seminar/conference room.
Tip 9: Provide a session for questions and clarifications. After the clinical encounter, sensitive issues are clarified in the absence of the patient to avoid embarrassment. In addition, all confusion with regard to the diagnosis is addressed. 
Tip 10: Time for feedback about the clinical encounter. Highlight the strength and weakness of the encounter. These will form the objectives of future clinical encounters. ,
Tip 11: Think about the bedside encounter and provide solutions for future encounter. The teacher should reflect on his strength and weakness and take steps to improve future encounter for the trainees and himself. 
Tip 12: Use lessons learnt from the present encounter to prepare for the next encounter. ,
Good strategies may not work if proper policies are not put in place. These policies will include placing equal emphasis on bedside teachings as didactic lectures, allocation of adequate bedside teaching period as distinct from lecture period to medical teachers, , departments should design their log books to reflect the importance of bedside teaching and finally, clinical skills assessment should form a part of the continuous assessment before the summative (final) examination. 
| Pitfalls to Avoid in Bedside Teaching|| |
Never call for a bedside teaching without adequate preparation and clear goals.
Do not ask a junior student, the same question that a senior student was unable to answer so as not to embarrass anyone. 
Never display the ignorance of the trainee in the presence of the patient. 
Never give the trainee an impression that you know the answer to all questions. This will discourage professionalism since continuous learning and seeking for knowledge is part of our calling as doctors. 
| Conclusion|| |
Bedside teaching remains the only viable option of teaching clinical skills in resource-limited countries. Reasons for the decline in bedside teaching have been highlighted in this article. Strategies to improve the effectiveness of bedside teaching have been categorised into three; before, during and after bedside teaching. These emphasise on adequate preparation and setting of clear objectives before teaching, active participation, and gentle correction during teaching and feedback discussion of sensitive issues away from the patient.
Bedside teaching is an invaluable tool and therefore it is recommended that actual empirical evaluation of its practices in our medical schools should be carried out with a view to improve bedside teaching and medical education, in general.
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