Year : 2020 | Volume
: 8 | Issue : 1 | Page : 9--10
Bedside clinical teaching: Arresting the decline
School of Medicine and Public Health University of Newcastle, Callaghan; Departments of General Medicine and Infectious Diseases, John Hunter Hospital, New Lambton Heights, NSW, Australia
Dr. Robert Pickles
School of Medicine and Public Health University of Newcastle, Callaghan, NSW 2308; John Hunter Hospital, New Lambton Heights, NSW 2305
|How to cite this article:|
Pickles R. Bedside clinical teaching: Arresting the decline.Arch Med Health Sci 2020;8:9-10
|How to cite this URL:|
Pickles R. Bedside clinical teaching: Arresting the decline. Arch Med Health Sci [serial online] 2020 [cited 2020 Aug 12 ];8:9-10
Available from: http://www.amhsjournal.org/text.asp?2020/8/1/9/287355
Numerous authors have cited the decline in doctors' clinical skills over the past decades, with many pointing to reduced time spent in bedside teaching and bedside rounds as being the primary reasons for this state.,
Both in undergraduate and postgraduate medical education, simulation is replacing real patient contact. Yet, we would do well to remember the words of Osler regarding the place of bedside teaching that “medicine is learned by the bedside and not in the classroom.” Medical school curricula are packed with more and more disease processes and diagnostic and therapeutic advances. Undergraduate clinical training during the first half of the 20th century was estimated to have taken place at the bedside for up to 75% of the time, falling to <20% today. In the face of advances in diagnostic (laboratory and imaging) technologies, it is no surprise that the time taken to obtain an accurate history and physical examination seems to have fallen by the wayside. Indeed, the less time spent in such activities, the less comfortable are practitioners in their performance at the bedside, potentially for fear of exposing their inadequacy, the so-called walking on the thin ice syndrome. Students and residents have been observed to omit parts of the physical examination and even examine over hospital gowns., It is often forgotten that a thorough history and physical examination alone can result in the correct diagnosis over 70% of the time. The consequences of the decline in these clinical skills lead to diagnostic delays and increased costs, as well as harms associated with unnecessary diagnostic tests. A recently published international survey found that physicians and trainees alike felt physical examination to be “almost always valuable.”
What are the barriers to bedside teaching that have been identified in the literature? Increasing reliance on diagnostic tests (almost as a substitute for clinical skills), hospital work practices that result in more time spent on computers, as well as increasing demands on clinicians' time have been commonly cited. Other excuses are patient discomfort and privacy concerns.
In the current environment where administrators are forced to focus ever more on costs of care along with shortened length of stay, declining clinical skills may paradoxically result in increasing costs to the system. Administrative directives that restrict clinical teaching during paid working hours are shortsighted and fail to recognize one of the central roles of academic institutions in the essential training of the workforce of the future. Shorter hospital stays, with ward teams caring for older, sicker patients with rapid turnaround times, reduce the time available for bedside teaching. US hospitalist data suggested that a census cap of 14 admitted patients improved a variety of metrics, including residents' perceptions of workloads as well as their job satisfaction. Higher workloads resulted in delays in care, poor communication, and a higher rate of complications.
Universities themselves have, over the years, increasingly appeared to value income-generating activities such as research over teaching. This has been understandable in an era of decreasing government funding of the university sector, where funding increasingly comes from research grants and overseas fee-paying students. Top researchers gain the most kudos, while the lower academic rungs within the institution are left with the “burden” of teaching. Clinical academics are often overburdened with clinical work, so as not to have adequate protected teaching time.
At times, patient discomfort and potential violation of privacy have been cited as reasons to favor conference room or simulation-based learning over bedside teaching. There is, in fact, a significant body of literature that suggests the opposite is the case, with patients and their families equating such contact with compassionate care. However, crowded four-bedded wards and patients in isolation rooms can pose difficulties.
What strategies are there to try to prioritize bedside teaching and improve the experiences of teachers, students, and patients? Medical schools could give greater protected time, financial rewards, and academic promotional opportunities to foster clinical teaching. My own institution has recently established an academy of clinical educators to try to address this issue and has employed extra clinical academics whose focus is explicitly on clinical teaching rather than research. Such programs also are capable of delivering teacher training to junior doctors, who, after all, comprise the future clinical teachers. The old adage “see one, do one, teach one” should no longer suffice.
Hospital departments can roster dedicated teaching time to attending physicians who are not on ward or outpatient service, thus spreading the load equitably. Dedicated teaching rooms with a supply of examination equipment can be made available. Local teaching hospital networks have published their experiences of successful strategies to encourage bedside teaching. Such activities may include structured physical examination curricula, although limitations of such approaches have been described. In addition, faculty development programs can be promoted, and teaching certificate programs can encourage clinician engagement. Clinical teaching, provided certain conditions are in place, ideally can be embedded within a physician's routine ward rounds so as to take advantage of the learning opportunities within the clinical context.
Clearly, the practice of medicine has undergone major shifts since the days of Sir William Osler, whose famous quote is still relevant today, almost 120 years later. By embracing technology and innovation in medical education, we can ensure that bedside teaching remains a vital component of the training of the future generation of clinicians. As Flexner said, the “facts are locked up in the patient, therefore the student must go to him.” This should be the way to teach and study medicine.
The author thanks Professor Balakrishnan Nair for helpful comments on earlier drafts of this manuscript.
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