11-3: YES!: Enhancing Bedside Teaching
November 03, 2023ID10939
To CiteDCA Citation Guide
- 00:00Yes is a
- 00:02yes is a year long series that gives
- 00:05us the opportunity to meet at this
- 00:07time on Friday is twice a month,
- 00:09this time on Fridays.
- 00:11So we welcome your ongoing
- 00:13attendance at the series.
- 00:15Doctor Andres Martin from Psychiatry
- 00:17in the Child Study Center and
- 00:19Doctor Dana Dunn from Internal
- 00:21Medicine are Co directors of YES.
- 00:23So I'd like to invite Doctor Martin
- 00:26now to let us know what we'll
- 00:28be doing today and to introduce
- 00:30today's presenter, Andreas.
- 00:33Thanks, John.
- 00:34Well, we're all in for a treat today and I
- 00:39won't take much time telling you about Jeff,
- 00:43but I'll share one or two things.
- 00:45As you can see, he is a neurologist.
- 00:47He's an associate professor in
- 00:49the Department of Neurology,
- 00:51Neurology assistant, associate.
- 00:52He should be a assistant.
- 00:56He's assistant. But you heard it here first.
- 00:58You heard it here first.
- 00:59He will be an associate
- 01:01sometime soon I'm I'm sure.
- 01:03And he is associate training director
- 01:07for the residency and it's interesting
- 01:09that he's a director of Wellness.
- 01:11I I say that because as you get to know
- 01:14Jeff and the time that I've met him
- 01:16you will see what a Zen master he is.
- 01:18He's a really incredibly calm and
- 01:23calming presence and and everything
- 01:25that he does in teaching and and
- 01:28so when I asked him what area of
- 01:29neurology he is dedicated to I thought
- 01:31it was going to be I don't know like
- 01:34some brain waves about calmness.
- 01:35No. He is an electromuscular Dr.
- 01:38Doctor so for a living he inserts needles
- 01:42into people pleasant experience but he
- 01:44is an expert at that and general neurology.
- 01:48So today Jeff is going to be telling us about
- 01:52the what I think could be in some places,
- 01:56the lost art of bedside teaching.
- 01:57But it is far from lost and with with
- 02:01teachers and educators like like Jeff it,
- 02:04it will not be lost.
- 02:05So let's learn about that bedside teaching.
- 02:07Jeff,
- 02:09thank you. Thank you all for having me.
- 02:11I don't usually get to join at this time.
- 02:12So I'm excited to to be part
- 02:15of the series and to attend
- 02:16today in my speaker role.
- 02:18I'll switch the next slide.
- 02:19Here's all the CME information
- 02:21you need to know.
- 02:23The code and the number are also in the chat,
- 02:26so don't feel like you have
- 02:27to frantically put that down.
- 02:32So we asked you ahead of time.
- 02:34You may have seemed to come with a
- 02:36mobile device, and this is going
- 02:38to be an interactive session.
- 02:39I hope to listen,
- 02:41maybe not as much as I speak,
- 02:43but at least a fair proportion of
- 02:45the time to what you have to say.
- 02:47And I've found that I know you all learned
- 02:49about Mentimeter at the last session.
- 02:51I found it's a really useful
- 02:52platform for teaching and we're
- 02:53going to use it together today.
- 02:55So the instructions will be
- 02:56at the top of every slide.
- 02:58If for any reason you get logged out,
- 03:00you'll also notice in the in the on
- 03:02your screen some slides will give you
- 03:03an opportunity to give a thumbs up.
- 03:05Some slides will give you an
- 03:07opportunity to ask a question.
- 03:08So if you have a question,
- 03:10just click on the question button and
- 03:11I'll be monitoring the bottom of the screen.
- 03:13Other ways to ask questions are
- 03:15to raise your hand in zoom or
- 03:16to drop them in the chat.
- 03:20So let's see if we got logged in.
- 03:21Please share with us a recent moment of joy,
- 03:25something that brought you joy.
- 03:26While we're waiting, I'll just share.
- 03:28We entered my dog in a Halloween costume
- 03:30contest last weekend at a local brewery.
- 03:33Anyone. Top prize?
- 03:34So that was my moment of joy that
- 03:36we dressed him up as serious black.
- 03:38He's a big black dog.
- 03:39And for those of you who know
- 03:40the Harry Potter series,
- 03:41that was his sort of alter ego.
- 03:43That character was a dog.
- 03:44So I see people who did some baking,
- 03:47some reorganizing,
- 03:48spending some time with family.
- 03:50Yeah.
- 03:52And and dogs. All right.
- 03:56This is good.
- 03:58I always get joy just reading these.
- 04:00I I hope you all do as well.
- 04:02And I'm happy to see that you're
- 04:04able to log in and use Ventimeter.
- 04:05So keep your phone handy.
- 04:08We are going to, I'm going to hit
- 04:10you with questions throughout this.
- 04:12Some will be free response.
- 04:13Some will be just polls,
- 04:15and you'll it'll give you a little
- 04:17taste of how I use mentimeter in
- 04:19an instructional level as well,
- 04:20although I can't say I've ever
- 04:21incorporated it at the bedside.
- 04:23So thank you for sharing
- 04:24these moments of joy.
- 04:26Please share what thoughts or
- 04:27feelings come to mind when you
- 04:29think about bedside teaching.
- 04:31These can be emotions.
- 04:32These can be key points
- 04:35about good bedside teaching.
- 04:37These can be personal experiences.
- 04:38But what do you think about,
- 04:44especially if someone told you,
- 04:45hey, today you have to go and you
- 04:47have to teach at the bedside,
- 04:48what does that make you feel?
- 04:51Well thank you for sharing a
- 04:52moment to join the chat too.
- 04:53I see that excitement, curiosity,
- 04:59fun, happy, valuable.
- 05:00I agree it's very valuable.
- 05:03There isn't.
- 05:04There is a performance elements
- 05:05that side teaching for sure,
- 05:07involving the patient,
- 05:08great 19th century sad emoji
- 05:14lost art. Yeah, you know,
- 05:16I agree with a lot of these points.
- 05:20Keep your senses peeled.
- 05:22Absolutely. Be curious.
- 05:25Awkward. It can certainly be awkward.
- 05:27I think with good with practice
- 05:29and good good practices,
- 05:30we can make it less awkward.
- 05:32Wish it was more common. I agree.
- 05:35Thank you for sharing that.
- 05:38Just so I know who I'm talking to.
- 05:39How long have you been in your
- 05:40role as a teaching faculty here?
- 05:41And it doesn't have to be here at Yale.
- 05:50It can be on any institution you're
- 05:52around. But where do we stand? We've
- 05:56got some junior teachers,
- 05:58some master teachers, some people
- 06:00who are perhaps younger masters.
- 06:05Interesting. We're missing the six to
- 06:0710 year demographic, but that's OK.
- 06:08So I think no matter how long
- 06:10you've been teaching for,
- 06:11you've probably done, oh,
- 06:13there we go. Good.
- 06:14You've done some bedside teaching.
- 06:16Some of you may make it central
- 06:18to your practice.
- 06:18Some of you may dabble and my
- 06:21hope is that you'll no matter what
- 06:22amount you do after this talk,
- 06:24you'll do a little more and you'll feel
- 06:26a little more comfortable doing it.
- 06:28So what percentage of teaching and
- 06:30learning is done in the presence
- 06:32of a patient in your practice?
- 06:33As a teacher and this,
- 06:35I want to know both in the ideal
- 06:37setting but also in reality,
- 06:38you know,
- 06:38with with the constraints of
- 06:40teaching at the bedside involved,
- 06:42where do you end up.
- 07:00This is fairly typical of what I
- 07:02see when I ask people this question.
- 07:03We all want to do more and I
- 07:07think that's very telling.
- 07:09Some of you would like to
- 07:10do it all of the time,
- 07:11some of you get to do it most of the time,
- 07:12which is pretty cool.
- 07:15Not all of us are are in that position.
- 07:17And again, I want to move you more toward
- 07:19your ideal by the end of this talk.
- 07:23One last question for now.
- 07:25Where do you teach?
- 07:49Yeah, so this is already approaching.
- 07:51Again, what I typically see when I have
- 07:54these conversations with teachers is
- 07:56the majority of teaching goes on as
- 08:00far away from the patient as possible,
- 08:01right in a conference room at a table,
- 08:04probably with a white board or a
- 08:05computer involved. And that's OK.
- 08:07And I'm not saying that's bad teaching.
- 08:09I think that could be very good teaching,
- 08:11but of course that's not our focus today.
- 08:13I always am interested in how much teaching
- 08:16goes on in the hallway sort of in that
- 08:18in that liminal space between the the
- 08:21conference room and the patient's bedside.
- 08:23And then of course we end up doing
- 08:25probably the least amount at the bedside.
- 08:27And there are many reasons for that
- 08:29which we're going to talk about.
- 08:31So let's let's define what
- 08:32we're talking about today.
- 08:33So my definition of bedside
- 08:37teaching is clinical teaching in
- 08:38the presence of a patient.
- 08:40So that can be teaching the exam,
- 08:42that can be teaching history,
- 08:46taking skills,
- 08:48presentation skills,
- 08:49rounding with the patient in in in front
- 08:51of the team and doing some teaching.
- 08:53In that setting it can be a total one
- 08:55off teaching session where you grab
- 08:57some students who are pre clinical and
- 08:59take them to the bedside to teach.
- 09:02So there are many ways to teach
- 09:03at the bedside,
- 09:03but really it's that presence of the patient
- 09:06that defines what we're talking about today.
- 09:08So bedside teaching has been around
- 09:10since really the the 17th century
- 09:13and and at least at least that long,
- 09:15probably not much longer,
- 09:17right,
- 09:17Probably since in the history of medicine
- 09:19there's always been bedside teaching,
- 09:20but this is a quote from Sylvia.
- 09:22So my method,
- 09:23hitherto unknown here and
- 09:25possibly anywhere else,
- 09:26is to lead my students by the
- 09:27hand to the practice of medicine,
- 09:29taking them every day to see
- 09:31patients in the public hospital.
- 09:33But they may hear the patient's symptoms
- 09:35and see their physical findings.
- 09:37And then I question the students
- 09:39as to what they have noted in the
- 09:41patients and about their thoughts
- 09:43and perceptions regarding the
- 09:44illnesses and principles of treatment.
- 09:46I couldn't put bedside teaching any better,
- 09:48right?
- 09:48Taking the students to the practice
- 09:51of medicine,
- 09:51to the bedside where they can
- 09:53learn from the patients.
- 09:55And of course we'd be remiss if
- 09:56we didn't find a no slick quote.
- 09:58There should be no teaching without
- 09:59a patient for a text.
- 10:01And the best teaching is that
- 10:02taught by the patient himself.
- 10:04So I find these quotes inspiring.
- 10:05They remind me how important
- 10:08bedside teaching is.
- 10:10I hope they do the same for you.
- 10:12Bedside teaching is not what it used to be.
- 10:14So if you look at the literature,
- 10:17back in the 60s we were teaching at least
- 10:20reportedly 75% of the time at the bedside,
- 10:23and now we're teaching perhaps less
- 10:26than 20% of the time at the bedside.
- 10:27And that kind of resonates with the
- 10:30data that you all gave me a moment ago
- 10:31as to where you spend most
- 10:33of your time teaching.
- 10:34So why is that? Well, let's,
- 10:37let's look at some more data first.
- 10:38So this is a busy table.
- 10:41I'm going to show you what's
- 10:42important in a second.
- 10:43But basically what this study did was it,
- 10:46it surveyed medical students and
- 10:48internal medicine residents and
- 10:49it asked them how much of your
- 10:51time is spent at the bedside
- 10:53during rounds with the attending?
- 10:55And then how many,
- 10:56what percentage of cases are
- 10:57you presenting at the bedside,
- 10:59So actually presenting the history,
- 11:01the differential diagnosis,
- 11:02the thought process and the clinical
- 11:05reasoning in front of the patient.
- 11:06And the,
- 11:07the real standout point here is first of all,
- 11:10if you look at the top numbers,
- 11:13somewhere between 1/4 and 1/3 of time
- 11:15is spent at the bedside on rounds.
- 11:18It's kind of crazy when you think about it.
- 11:20But in terms of case presentations,
- 11:23the vast majority are presenting 25%
- 11:27or less of their cases at the bedside,
- 11:29meaning most cases are being presented,
- 11:31thought through,
- 11:32discussed in a conference room
- 11:33or in a hallway.
- 11:53So why, why do you think that is
- 11:57much data the time it takes?
- 11:59We'll talk about time in a little bit.
- 12:02Yeah. COVID has absolutely
- 12:03changed how we round and teach
- 12:06the reliance on the EMRI.
- 12:07Agree confidentiality is an issue,
- 12:09especially in crowded rooms, right,
- 12:11with two or more patients in a room,
- 12:14busy schedules.
- 12:17Let's see. There's a lot of answers here.
- 12:18Time. Afraid of patients and needing
- 12:20the computer to enter orders.
- 12:22That comes up a lot.
- 12:23I think this is an important one.
- 12:25Afraid. Afraid of saying something
- 12:26that upsets the patient,
- 12:27and it may be related to also needing
- 12:31to make joint decisions and it may be
- 12:35information overload for the patient if
- 12:37you present everything in front of them.
- 12:39Resistance for patients and families,
- 12:41shared rooms, patient privacy.
- 12:42We have a lot more info on the patients now,
- 12:45Absolutely.
- 12:45So we we know more than we ever did
- 12:48before in terms of data to process and
- 12:51visiting visiting hours have changed.
- 12:52So presenting with family there versus
- 12:54without is always, always an issue.
- 12:56Great.
- 12:59So you all covered what
- 13:01the literature tells us.
- 13:02Our workload has increased,
- 13:04patients are off the floor more we
- 13:07we do worry about burdening patients.
- 13:09This is a legitimate fear that's
- 13:10cited in a lot of bedside literature,
- 13:12Bedside teaching literature.
- 13:14The conference room is more comfortable.
- 13:16I didn't see that come up,
- 13:17but I hear that often it's much
- 13:19nicer to sit around a table
- 13:21than to stand around a bed.
- 13:23And we do use the computer a ton.
- 13:26And even I think mobile,
- 13:27mobile based Epic or things like it have
- 13:30not pulled us away from the computer.
- 13:32Perhaps as much as we would like.
- 13:34Imaging needs big screens to review.
- 13:36You know,
- 13:37there's lots of data that needs big screens,
- 13:50but why should we?
- 13:51Then we've talked about why not.
- 13:53Why do you think it's so important?
- 13:55You all came here for a reason to
- 13:57discuss and think about this topic.
- 14:01The exam matters. You know, as a
- 14:03neurologist, I couldn't agree more.
- 14:08Helps us patients know we were
- 14:09thinking hard about them.
- 14:10Yeah. And there there actually
- 14:11is data to support that.
- 14:12It engages the patients.
- 14:15The patients are at the core of what we do.
- 14:17It's our our primary value.
- 14:19So we should express that improves
- 14:22patient and medical team relationships.
- 14:24Absolutely.
- 14:24Patients can correct what we've got wrong.
- 14:28Very important.
- 14:28You know we a lot of times we present off
- 14:31a note that was written the night before
- 14:33by a different person who's not there.
- 14:35Data can get lost in the game
- 14:38of telephone that we play.
- 14:39There's a human connection aspect.
- 14:40Absolutely.
- 14:41Patients can feel involved and informed.
- 14:45I couldn't agree with any of these more,
- 14:51right? So again,
- 14:53you all are are hitting right on the nose.
- 14:56So if you look at the literature to
- 14:59support why we should teach at the bedside,
- 15:02hands on learning is irreplaceable.
- 15:04You know, especially when we teach the exam,
- 15:08you can only do so much on SIM models,
- 15:11on each other, on even standardized patients.
- 15:14Really seeing pathology upfront is crucial.
- 15:19Patients appreciate it and
- 15:20there's data to support this.
- 15:21So if you this is an even busier table and
- 15:23I'll show you what's important in a second.
- 15:25But the this study was done
- 15:27in 97 and they asked patients
- 15:30about presenting at the bedside,
- 15:31How do you feel about it?
- 15:33What is, what aspects of it
- 15:36come across well to you?
- 15:37And they asked them about
- 15:39explanation of problems,
- 15:40explanation of tests and medications,
- 15:43whether or not the team treated
- 15:45them with respect and introduced
- 15:46themselves and what was their overall
- 15:48experience of rounds were round,
- 15:49satisfying, Were rounds worrisome?
- 15:52Was care ideal?
- 15:54And if you look at the adjusted odds ratios,
- 15:57unfortunately none of
- 15:59these reached significance.
- 16:00But there was the clear trend
- 16:02toward the odds of patients
- 16:05getting better explanations,
- 16:07having a better interpersonal experience,
- 16:09and overall enjoying the rounds more if
- 16:12their case was presented in front of them.
- 16:15So this is not even necessarily teaching,
- 16:17but I think it is because we teach
- 16:19when we learn from presentations.
- 16:21But discussing patient care in front
- 16:24of the patient is a good thing.
- 16:26That's what I get out of this study.
- 16:29This was another table from the same
- 16:31study where they asked patients
- 16:34about their perceptions of bedside
- 16:36presentation and bedside teaching,
- 16:38and the majority percentage said
- 16:40it was not upsetting to them.
- 16:43The the majority said they should
- 16:45continue teaching at the bedside.
- 16:47A minor majority said it helped
- 16:50them understand their illness and
- 16:52they gave us some points of caution
- 16:54about using too much terminology
- 16:56and about focusing on trainees
- 16:58as opposed to the patient.
- 17:00So they gave some suggestions as well,
- 17:01which had various levels of support.
- 17:04But things like patients should be
- 17:06encouraged to say more during rounds.
- 17:08Everyone should introduce themselves.
- 17:10I think that's the best practice.
- 17:12Fewer,
- 17:12fewer physicians perhaps should be present,
- 17:15although not very many said that and there
- 17:18were a few other sort of minor points.
- 17:19But again,
- 17:20I think this reinforces the point that
- 17:22patients don't get upset when you
- 17:24talk about them in front of them and
- 17:26in many cases they can appreciate it.
- 17:30Learners definitely
- 17:31appreciate bedside teaching.
- 17:33So this study looked at just asks
- 17:37learners a different study from
- 17:39the same year what did you think
- 17:42about being taught at the bedside
- 17:43And they felt that it increased
- 17:45their understanding of the problem.
- 17:46They enjoyed it.
- 17:48It didn't necessarily make them
- 17:50anxious if it was done well.
- 17:53The minority only the minority of
- 17:56cases discussions were inappropriate.
- 17:58There could have been maybe
- 17:59better pre briefing and we'll talk
- 18:01about how to do that effectively,
- 18:03but most of them thought it didn't
- 18:06reach confidentiality and they we
- 18:08didn't get into getting it into,
- 18:09you know, room setups.
- 18:10How many of these were in private rooms
- 18:12and would you recommend it to others?
- 18:15The majority said yes,
- 18:16so learners love it,
- 18:17but why not do more of it?
- 18:20It's also consistent with what
- 18:21we know about how adults learn.
- 18:23And I know there's not one
- 18:25definite adult learning theory,
- 18:26but there are a few out there that
- 18:28agree well with bedside teaching.
- 18:30So this is from a lot of literatures
- 18:33from 1997 on bedside teaching,
- 18:35it must have been a themed issue,
- 18:38this journal.
- 18:40But there are a few principles
- 18:42of adult learning that I think
- 18:43we need to accept in order to
- 18:45be good bedside teachers.
- 18:46So the first is that knowledge is
- 18:48continuously revised by applying
- 18:50experience to prior knowledge and
- 18:52it's really getting that experience
- 18:54that we're doing as bedside teachers.
- 18:56Expert clinical reasoning is based
- 18:58on a repertoire of experience.
- 18:59And again,
- 19:00we're building that by teaching
- 19:01at the bedside.
- 19:02Adult learners must have ownership
- 19:04in the learning activity and I
- 19:06think putting them on the spot at
- 19:08the bedside really does that well.
- 19:10And adult learning is a social activity.
- 19:11It's best done in groups and bedside
- 19:13teaching is done in a small group setting.
- 19:15So these are principles to accept
- 19:17and I'd be curious maybe if
- 19:19we have time at the end if you
- 19:21disagreed with any of these.
- 19:24There's also the theory of situated learning,
- 19:26and this is one of my favourites as far as
- 19:30potentially valid theories of adult learning.
- 19:32But the idea of situated learning,
- 19:34for those who don't know it,
- 19:35is that learners start at the periphery
- 19:38of the the context of their learning.
- 19:41And so in medicine they started the
- 19:43periphery of the practice of medicine,
- 19:45and as they interact with
- 19:46experts who support them,
- 19:48they move toward the center of their context.
- 19:52Until they don't,
- 19:53they themselves become experts and
- 19:55begin to support other novice learners.
- 19:57And so this is done through activities,
- 19:59through artifacts,
- 20:00through identities,
- 20:01and through relationships and I think the
- 20:03activities and relationships aspects.
- 20:05Of situated learning are really,
- 20:07really where bedside teaching
- 20:10is extremely powerful.
- 20:11We're building relationships with patients,
- 20:13we're building relationships with each
- 20:15other and we're doing activities that
- 20:17are central to the practice of medicine,
- 20:19examining patients,
- 20:20clinical reasoning and educating
- 20:22the patients themselves.
- 20:27So let's talk about efficiency for a minute.
- 20:29Because the time came up, we've talked
- 20:32about reasons why bedside teaching is tough
- 20:38and why did it do it. And one of
- 20:40the reasons you mentioned was time.
- 20:42Where is the most efficient place
- 20:44in your experience to teach?
- 20:52And I'm talking about educational
- 20:53bang for your buck here.
- 20:57OK, So we got a fair mix.
- 21:04Yeah. And this is consistent with
- 21:08my discussions with teachers and
- 21:10my experience helping people learn
- 21:11how to teach at the bedside.
- 21:15I I find understanding that we
- 21:16ranked hallway the highest.
- 21:17I think there's something to be
- 21:18said for that when you're out
- 21:20of the presence of the patient,
- 21:21but still in that patient care context,
- 21:24perhaps you get a lot of,
- 21:25a lot of bang for your buck.
- 21:27But I'm going to argue from the next
- 21:29moment here that bedside teaching
- 21:31is not necessarily inefficient.
- 21:32And when done well,
- 21:33it can even be more efficient than
- 21:35teaching in the conference room.
- 21:37So this was a
- 21:40study of effective teachers and
- 21:41they did a time in motion study.
- 21:44And so they looked at the
- 21:46most effective teachers,
- 21:47the medium effective teachers,
- 21:49and the least effective teachers.
- 21:50And they they looked at how they
- 21:52spent their time on rounds and how
- 21:55many teaching activities they did.
- 21:56So it won't surprise you
- 21:58to see that for instance,
- 21:59the most effective teachers did the
- 22:01most number of teaching activities
- 22:03on rounds by by a large handful,
- 22:06maybe not significant, but there's a trend.
- 22:08What I think is really interesting
- 22:10in this slide is the number of the
- 22:12amount of time that the effective
- 22:14teachers spent on rounding versus
- 22:16the least effective teachers.
- 22:18So it there was a clear divide where
- 22:20these most highly effective teachers
- 22:22actually were the most efficient on rounds.
- 22:26And yet, if you look down to lines below,
- 22:29they did the most number of
- 22:31teaching activities for patients.
- 22:33So I think the question we have to
- 22:34ask ourselves is what are these,
- 22:35what are these teachers doing right,
- 22:37where they can teach more and
- 22:39spend less time doing?
- 22:40And I think a lot of that has to do
- 22:42with where they did their teaching,
- 22:43which was at the bedside.
- 22:46So let's talk about how to
- 22:47do bedside teaching.
- 22:48Well,
- 22:48that's where we're going to spend
- 22:50the next half hour of our time.
- 22:52So I want to hear from you first,
- 22:53what are the characteristics of a good
- 22:55teaching encounter at the bedside?
- 23:24Everybody participates. Yeah.
- 23:28It's succinct. It's directed,
- 23:30It's collaborative, focused,
- 23:33motivated by curiosity and
- 23:34active in its teaching,
- 23:36allowing time for questions.
- 23:42Yeah, the patient needs well, I don't know.
- 23:45As someone who teaches on patients in comas,
- 23:47do they need to be awake?
- 23:50Depends. It depends.
- 23:53But I like all these points.
- 23:54I think these are great points
- 23:55and I appreciate you sharing them.
- 23:56I'm going to make,
- 23:58I'm going to spend my time for the next 25
- 24:01minutes really focusing on two big ideas,
- 24:04and we'll talk about the
- 24:06details of those ideas.
- 24:07But all of the things that you're
- 24:09saying here and continue to say are
- 24:11relevant to good bedside teaching,
- 24:12we'll talk about ways to do some of them.
- 24:14For instance,
- 24:15how to include the patient,
- 24:16how to get everyone to participate.
- 24:18I like the phrase zone of proximal
- 24:21developments.
- 24:21I think that's a really important concept.
- 24:25But the big ideas are this effective.
- 24:28Bedside teaching really has three phases
- 24:30and if you do all of these phases,
- 24:32you're almost guaranteed to succeed.
- 24:34So the first is preparation,
- 24:35the 2nd is execution,
- 24:36and the third is debriefing.
- 24:37And I'm going to use this three-step
- 24:39model as I talk about the next point,
- 24:42which is that good bedside
- 24:44teaching encounters are both
- 24:46learner and patient centered.
- 24:48And you have to do both in
- 24:50order to really be effective.
- 24:51And all we're going to talk about the
- 24:53rest of the time is how to do that.
- 24:55So let's talk about learner
- 24:57centered teaching for a second.
- 24:59The big dynamic we probably spend a lot
- 25:00of time thinking about as teachers is
- 25:02how are we interacting with our learners?
- 25:04How are they interacting with us?
- 25:06How are we monitoring their learning and
- 25:08ensuring that it's actually happening?
- 25:10How are we encouraging retention?
- 25:12You know this is the essence
- 25:14of teaching right?
- 25:15Is is this teacher run a relationship
- 25:19learner centered teaching.
- 25:20The best definition I've seen is
- 25:22this a method of teaching in which
- 25:24the students needs have priority.
- 25:26Teachers are expected to facilitate
- 25:28self-directed learning instead instead
- 25:30of supplying spoon fed information.
- 25:32And this is the opposite of
- 25:34teacher centered education.
- 25:35The simpler way to put it would be
- 25:36teaching what the learner needs to teach,
- 25:38not what you want to teach.
- 25:39And those do not always overlap.
- 25:41In fact, often they don't and
- 25:43that's what makes learner centered
- 25:45teaching so challenging.
- 25:47But again, the key points are this.
- 25:48It addresses the learner's needs,
- 25:50which some of you said in that word cloud.
- 25:52It's contextual and timely,
- 25:53which all of you said and it
- 25:56facilitates experiential learning.
- 25:58So learning through practice and experience.
- 26:00And you may or may not be familiar
- 26:02with the experiential learning cycle,
- 26:04but what we're really doing is providing
- 26:07this, these two top items here.
- 26:10So learning,
- 26:11experiential learning begins
- 26:13with concrete experience,
- 26:14moves into reflective observation.
- 26:18And this is what we're doing
- 26:19when we teach at the bedside.
- 26:20We're giving students or learners hands
- 26:22on experience and then encouraging
- 26:24them and helping them reflect.
- 26:26And that's where debriefing is
- 26:28so important on what they did
- 26:30and what they learned.
- 26:31And then we give them time
- 26:32and we allow them to form,
- 26:34abstract these concepts from what they
- 26:36learned and experiment with those concepts
- 26:38in their future interactions with patients.
- 26:41So again,
- 26:41we're moderating these first
- 26:43two steps if we do it right.
- 26:45So let's talk about the preparation phase.
- 26:48I think the two keys to preparing
- 26:51in a learner centered manner are
- 26:53selecting appropriate patients
- 26:54for learning and then establishing
- 26:56learning objectives based on
- 26:57what the learners need to know.
- 27:01So let's talk about patient
- 27:03selection for a minute.
- 27:04How important or how comfortable are you
- 27:07teaching in these these settings overall,
- 27:12when there's an unusual exam
- 27:13finding which may or may not be
- 27:16serious but is worth multiple
- 27:17learners seeing or experiencing?
- 27:20When the patient has a serious
- 27:22terminal diagnosis or prognosis
- 27:23and is cognitively intact.
- 27:24In other words, the conversation
- 27:26could get difficult in the moment.
- 27:28And then what about teaching
- 27:30on patients who aren't awake,
- 27:32who are encephalopathic for instance,
- 27:34or even in the coma?
- 27:56wow, you all are are feeling
- 27:57pretty comfortable. That's good.
- 27:58You should be teaching this instead of me.
- 28:02You know, it's it's an interesting
- 28:04phenomenon that I've seen as I
- 28:06asked this question of many groups,
- 28:07encephalopathic and comatose always wins.
- 28:10And I wonder when we talk about moderating
- 28:15the patient learner interaction,
- 28:16I wonder if that has something to do with it.
- 28:19But I'm glad to see that most of you are
- 28:21fairly comfortable because if you're if
- 28:23you're uncomfortable you need more practice.
- 28:25But also that's probably the biggest
- 28:27barrier to doing it is getting
- 28:29over that personal discomfort and
- 28:31some of you are and that's OK.
- 28:33Our goal is to make you more comfortable.
- 28:37So thinking about those groups of
- 28:39patients and other patients perhaps
- 28:41that you've taught on recently or not
- 28:44taught on recently for for a reason,
- 28:47What characteristics should
- 28:48we think about when we select
- 28:49patients for bedside teaching,
- 29:09appropriate mood?
- 29:09Yep, the patient agrees to it.
- 29:11We're going to talk
- 29:12about consent in a bit.
- 29:16Awakeness again, I think the patient being,
- 29:19I think what you may be referring
- 29:20to is if the patient is asleep,
- 29:22don't wake them up if you don't have to.
- 29:26But there's also the spectrum of
- 29:29AWAKEN ALERT versus encephalopathic,
- 29:31stuporous or comatose.
- 29:33What is their health literacy appropriate?
- 29:35Yeah. Can you prepare them ahead of time?
- 29:38I think that's always good if you can,
- 29:39avoiding usually agitated patients,
- 29:41which you're going to run into for sure
- 29:44agreeable to having a learner join them.
- 29:47The learner's interest in the topic.
- 29:49Yeah, so that's part of learner
- 29:51centered teaching is, you know,
- 29:53do the learners want to learn about
- 29:54what you're going to teach them?
- 29:56Hopefully as a motivated adult learners,
- 29:58there they do.
- 29:59But that's not always the case.
- 30:01Religious and cultural beliefs
- 30:03regarding groups and teaching,
- 30:06considering the family's thoughts
- 30:07and teaching the presence of
- 30:08a family is a whole another.
- 30:09It's probably an hour onto itself.
- 30:13A good physical exam.
- 30:14I'm not intrusive to other parts.
- 30:15Yep. Engage ability,
- 30:17all all great things to think of.
- 30:19If you go to the literature on this,
- 30:20there's not much,
- 30:22and I think some of that's because
- 30:24this is maybe considered common sense,
- 30:25but I think there's an art to
- 30:27picking the right patient one.
- 30:31Oops.
- 30:32One the table that I found that I
- 30:35thought was helpful is this one.
- 30:37And these are things you can think about,
- 30:39some of which you've already mentioned
- 30:41in terms of how to pick the best
- 30:42patient from bedside teaching.
- 30:43So does it fit the lessons topic?
- 30:48Makes sense Language and verbal skills.
- 30:51One thing to consider is,
- 30:53is a non-english speaking patient
- 30:55a barrier to bedside teaching?
- 30:57Yes,
- 30:57but should we deprive those patients
- 30:59of the benefits of bedside teaching?
- 31:01I would argue no.
- 31:03And so if an appropriate
- 31:04interpreter can be found,
- 31:05including patients who are non-english
- 31:07speaking is very important.
- 31:09Their state of health right?
- 31:11Are they tenuous?
- 31:13Are they in step down unit and quite sick?
- 31:16Are they in an ICU?
- 31:17And how much teaching is appropriate
- 31:19on a patient who's critically,
- 31:20I'll for instance,
- 31:22interactions down on personality,
- 31:24the dangers of infection?
- 31:25Speaking of COVID,
- 31:27is it appropriate to bring a large group
- 31:29into a patient on contact precautions,
- 31:32their own insight into the disease?
- 31:34And I think bedside teaching is
- 31:35a chance to develop that insight.
- 31:37But thinking about where they're
- 31:39starting is really important and what's
- 31:40your relationship with that patient?
- 31:42If they're angry at the team,
- 31:43probably not a great day.
- 31:44Ask them if they're OK with being taught
- 31:46or taught on or included in teaching.
- 31:49And then there's some
- 31:50structural factors to consider.
- 31:51How many patients do you have to round on,
- 31:54and how many?
- 31:55How many of those are?
- 31:56Can you really logistically teach on?
- 32:00Maybe don't teach on the same
- 32:02patient every day.
- 32:02Frequency of participation.
- 32:04What's the lesson schedule?
- 32:05Can you contact the patient?
- 32:07Are they on the floor?
- 32:08And then of course,
- 32:08any legal aspects always need
- 32:10to be considered as well.
- 32:11So these are things to think about.
- 32:13But the ideal patient is somebody
- 32:16who ideally can participate.
- 32:17Unless you're trying to teach,
- 32:20the comatose exam is agreeable
- 32:23to participate.
- 32:24Again,
- 32:25I I think language should be thought about
- 32:27very carefully and then has something
- 32:30that's worthy of of being taught,
- 32:33right?
- 32:33And that could be an exam finding.
- 32:34That could be modeling the
- 32:36patient doctor interaction in
- 32:37a difficult conversation,
- 32:39That could be modeling patient education,
- 32:43or it could be practicing
- 32:45clinical reasoning and explaining
- 32:46thought processes to the patient.
- 32:47So it doesn't have to be the physical exam,
- 32:50but something that's relevant to
- 32:50what the learners need to know.
- 32:52I'm not going to get too much into the
- 32:55second point of preparation because that's
- 32:57determining learner objectives is really
- 33:01hours of lecture all unto themselves.
- 33:05But I just want to talk about how to execute.
- 33:08So we'll go on to the next phase.
- 33:11How do you execute a good
- 33:13bedside teaching encounter?
- 33:13I think it starts in the doorway.
- 33:15And so I think reviewing the
- 33:17learning objectives that you may
- 33:18have developed earlier in the day,
- 33:20for instance on table rounds,
- 33:22reviewing those objectives right before
- 33:24you go in to see the patient is important.
- 33:26Adapting the teaching to the learning needs,
- 33:28being learner centered,
- 33:30allowing for questions in the moment is key.
- 33:32So not not shying away from questions.
- 33:36I think this can be really nerve
- 33:38wracking as a bedside teacher
- 33:40because you don't know what you're
- 33:42going to get asked and you can be.
- 33:43There's a lot of thin ice phenomenon
- 33:45where you're going to be afraid to
- 33:47be put on the spot for something
- 33:48you may not know the answer to.
- 33:50But I think that's a chance to model
- 33:51how you find the answers to things
- 33:53and how you go back and and tell the
- 33:54patient what you want them to know
- 33:56and then give real time feedback.
- 33:58So don't don't necessarily wait
- 34:00until you're outside the room.
- 34:01I think there's a lot of value in
- 34:04giving feedback in front of the patient.
- 34:06There are many models and ways to do this,
- 34:09but one that I'm I'm very fond of
- 34:10is called the One minute Preceptor.
- 34:12You've probably seen it before.
- 34:13I'm not going to belabor it here,
- 34:16but it's a way to teach in a minute or less,
- 34:18maybe 2 minutes. One minute's a little.
- 34:20A little optimistic perhaps,
- 34:22but and you can do this in phases too.
- 34:24You can do some of this in pre rounds,
- 34:26some of this at the best side and
- 34:27some of this in the hallway.
- 34:28But get a commitment from the learner.
- 34:31So figure out,
- 34:33ask them to put their money down
- 34:35on something.
- 34:35What do you what do you think
- 34:36is going on here?
- 34:37What do you think is the cause?
- 34:39What is your treatment of choice?
- 34:40What diagnostic tests are next?
- 34:43Something that asks them to make
- 34:45a commitment and then ask them why
- 34:46probe for supporting evidence?
- 34:47Why do you think that?
- 34:49Why is this the best treatment?
- 34:50Or why would you do this as your next test?
- 34:53This then tells you what you need to teach.
- 34:55So if you do this either in front
- 34:57of the patient or right before you
- 34:59go to see them, now you know.
- 35:00This is how I'm going to teach to
- 35:02the learner's needs and not to my
- 35:04own comfort level,
- 35:05and then teach them something
- 35:07widely applicable.
- 35:08Here's how I do the reflex
- 35:10exam in somebody in bed.
- 35:11Here is how I check a wound
- 35:14to make sure it's truly clean,
- 35:16dry and intact. Whatever.
- 35:19Reinforce what the learner did well.
- 35:21So make sure that and you can do this
- 35:22at the bedside or in the hallway,
- 35:23but make sure they understand what
- 35:25what their strengths are and then
- 35:27give them some corrective feedback.
- 35:28What do you need to do better?
- 35:30So if you do this well, it's quick.
- 35:32And I think the best teachers are doing this,
- 35:35perhaps without even knowing
- 35:36they're doing it.
- 35:37And in fact that's how this
- 35:38model was developed,
- 35:39is they they observed excellent teachers
- 35:41and then did an ethnographic study and
- 35:44pulled out the behaviors they had in common.
- 35:47So good teachers are already doing this.
- 35:48You may already be doing this and
- 35:50feel free to implement it as a way to
- 35:52execute learner centered teaching.
- 35:53And then you want to debrief.
- 35:57So review the learning objectives,
- 35:59Provide some additional feedback,
- 36:00especially feedback you don't want
- 36:02to give in front of the patient.
- 36:04You know,
- 36:05things that are a little either
- 36:06maybe a little harsh or could
- 36:08embarrass the learner that you
- 36:10want to give in person without the
- 36:11rest of the team there and then
- 36:14allow for some time for reflection.
- 36:16Remember that abstract conceptualization
- 36:17and reflection are part of that
- 36:20experiential learning cycle.
- 36:21So ask them what did you learn from this?
- 36:23What are you going to take
- 36:25away for future encounters?
- 36:26What do you want to do differently
- 36:28the next time and and really guide
- 36:30some of that reflection in real time.
- 36:32So again,
- 36:33this doesn't have to be done
- 36:34in front of the patient,
- 36:35but it doesn't have to be done in
- 36:36order to do an effective learner
- 36:39centered teaching encounter.
- 36:41But remember,
- 36:43the bedside teaching encounters are
- 36:44both learner and patient centered.
- 36:46So we're going to,
- 36:46we're going to move on to talk about
- 36:48how to do patient centered encounters.
- 36:53And really what's happening now is
- 36:55we're introducing A complication
- 36:57to that initial dynamic.
- 36:58So instead of just a teacher and a learner,
- 37:00it's now as the teacher.
- 37:02You're moderating the
- 37:03teacher learner interaction.
- 37:05You're moderating your
- 37:06interaction with the patient,
- 37:07and you're also moderating the
- 37:09learner's interaction with the patient.
- 37:11So this is quite challenging you you
- 37:13just went from 1 interaction to three,
- 37:16but it still has three phases and
- 37:18good patient centered teaching,
- 37:20similar to learner centered teaching
- 37:22addresses the patient's needs,
- 37:24actively includes the patient,
- 37:26and facilitates patient education.
- 37:28So a lot of the same principles apply,
- 37:31you just need to moderate.
- 37:33You need to juggle multiple
- 37:35interactions at once.
- 37:36So how do you prepare in
- 37:38a patient centered way?
- 37:39So I think selecting patients
- 37:41based on the risk and benefits to
- 37:43them and ethical considerations.
- 37:45So risk benefits.
- 37:46A funny thing to think about
- 37:47when it comes to teaching,
- 37:49but it's a reality, right?
- 37:51There is a risk to being
- 37:53included in education.
- 37:54You may be uncomfortable,
- 37:56You may feel embarrassed.
- 37:58You may have confidential information
- 38:00discussed in front of a group.
- 38:02Your neighbor may overhear
- 38:03what's going on in the room.
- 38:05There's a lot to think about there,
- 38:07but there's a lot of benefit too.
- 38:09You will understand your condition better.
- 38:11You will know what your team is thinking.
- 38:12You will have benefited future
- 38:14patients because of the learners that
- 38:17you're teaching and then the ethical
- 38:19considerations that we discussed before.
- 38:21So pick the right patient,
- 38:24establish objectives based on
- 38:25what the patient needs from you.
- 38:27Do they need more education on
- 38:29the nature of their condition?
- 38:31Do they need to be included in a
- 38:33more active way in the discussion
- 38:35of their treatment plan?
- 38:37What can you do as a teacher
- 38:38to model these things and also
- 38:40accomplish what the patient needs?
- 38:41And then I would add a third
- 38:43element to this preparation,
- 38:44which is get consent from the patient.
- 38:47So I put a question mark there
- 38:49because I think this is an
- 38:50interesting question to think about
- 38:52at an academic Learning Center.
- 38:54So I want to know what you think.
- 38:56Should we be consenting patients
- 38:58explicitly for bedside teaching?
- 38:59And we'll talk about what the
- 39:00consent includes in a minute.
- 39:01But at least asking one question,
- 39:05do you want to be included
- 39:11or not?
- 39:14OK, so we're pretty evenly split
- 39:17here between always and sometimes.
- 39:20That, again, is pretty consistent
- 39:22with what I've seen in the past.
- 39:23Some people say, well,
- 39:26you're at an academic center,
- 39:27so it's implied that there's
- 39:29going to be teaching involved.
- 39:30And you don't necessarily
- 39:31need to ask every patient.
- 39:33Some people say the patient
- 39:34didn't get to choose to be
- 39:36admitted to an academic center.
- 39:37We may have just been the closest
- 39:39center to them and they would have
- 39:41preferred to be at a private hospital
- 39:42and want to be treated that way.
- 39:43So you always need to find out are
- 39:45they OK with being taught on Both
- 39:47points are valid and I'm not gonna
- 39:49make a case today for either one,
- 39:51but I'm gonna talk about how
- 39:53you consent to patients,
- 39:54if you want to consent them,
- 39:55if you feel that it's important.
- 39:57So what do you think you should
- 39:58include in that conversation?
- 40:23If they're up for it, What topic?
- 40:26Yeah. When they have questions,
- 40:28a quick description of what
- 40:29they should expect. Absolutely.
- 40:32Is it OK to talk just to learners?
- 40:34Yeah, More of an ascent.
- 40:36A brief expectation of what to expect.
- 40:38Rules of engagement.
- 40:39I like that phrase.
- 40:41Anything they want to avoid?
- 40:42Absolutely. Letting them know
- 40:44that others may be joining you.
- 40:46Giving a patient the scope of the visit,
- 40:47Informing them how many people will be there,
- 40:50anything they want to cover. Yeah.
- 40:51So what do you want to talk about?
- 40:53What don't you want to talk about?
- 40:54Assuring them that it's
- 40:56safe structure and timing.
- 40:58These are all excellent points,
- 41:00and I think you can cover most of
- 41:02these in a couple of sentences.
- 41:03So we're not talking about
- 41:05informed consent for surgery here,
- 41:06but we we are talking about
- 41:09some aspect of consent.
- 41:10Again, when you go to the literature on this,
- 41:12there's not a lot,
- 41:13but the literature suggests at
- 41:15least including three things.
- 41:17So one is, do they consent?
- 41:18Are they OK with that?
- 41:19Are they up for it? Can we do it now?
- 41:21Are they too tired?
- 41:23Whatever #2 is this choice,
- 41:25letting them know you can
- 41:26say yes or you can say no,
- 41:28and neither choice is going to affect
- 41:30your care in an appreciable way.
- 41:32We're going to care for you the same
- 41:33regardless of whether we do some teaching.
- 41:35And then the third is that even
- 41:37though there's a group here,
- 41:38you're and we may discuss you
- 41:41as a patient on post rounds.
- 41:43We're not going to spread
- 41:45your information to others.
- 41:46This is not going to go,
- 41:48you know,
- 41:49in somebody's Twitter account or whatever.
- 41:51So assert patients of that is really
- 41:53key and getting their consent and
- 41:54letting them know they have choice.
- 41:56If you include those three things and
- 41:58you can do that in one or two sentences,
- 42:00that's an adequate consent or
- 42:02something like this, The risk is low.
- 42:04The benefit is moderate to high
- 42:07and it's fairly straightforward.
- 42:10So you've consented the patient,
- 42:12you've selected them,
- 42:13you've established learning goals.
- 42:14They know what's coming.
- 42:17What do you actually do
- 42:18when you're at the bedside?
- 42:19So I think before you go in,
- 42:21just like you had a doorway review
- 42:23of the expectations you need to
- 42:25have or the learning objectives,
- 42:27you need to have a doorway
- 42:28review of expectations.
- 42:29What do we think the patient needs from this?
- 42:31And what did they tell
- 42:32us they want from this?
- 42:33And that includes what they wanted
- 42:35and what they wanted to avoid.
- 42:37When you get in there,
- 42:38make sure you involve the patient.
- 42:40We're going to talk about some
- 42:41ways to do that in a second.
- 42:43Also make sure as a way of involving
- 42:45them that you summarize what's
- 42:46going on so that they understand it.
- 42:48Translate jargon into patient
- 42:52centered language.
- 42:54Allow for the patients to ask
- 42:55you questions just like you
- 42:57allow for the learners to ask you
- 42:58questions and get feedback from
- 43:00the patient for the learner.
- 43:01What what did you like about the way
- 43:04this person examined you or what do you
- 43:07know now that you didn't know before?
- 43:09And so getting getting that feedback
- 43:11from the patient is really invaluable.
- 43:13That's probably the thing we get the
- 43:15least is effective patient feedback
- 43:18on what we're doing as clinicians.
- 43:21So seize that opportunity.
- 43:24This is a really interesting
- 43:26study that was done.
- 43:27It was an ethnographic study
- 43:29and it was done on teams that
- 43:31were teaching at the bedside.
- 43:32When they looked at videos of these
- 43:34teams and study their behaviors
- 43:36and what they found was that they
- 43:39really fit into two categories.
- 43:41So one was called patient as body
- 43:43and this is where the patient was
- 43:45used essentially as a teaching prop.
- 43:47So the patient was discussed in a
- 43:49separate way in a way that made
- 43:51them feel perhaps excluded from the
- 43:53conversation or didn't acknowledge them.
- 43:55Medical jargon was used and the
- 43:57patient was non verbally excluded.
- 43:59In other words,
- 44:00the team was clustered at the
- 44:02foot of the bed.
- 44:03They sometimes even blocked the patients
- 44:04out or had their backs to the patients,
- 44:06and they were discussing them
- 44:08as if they weren't there.
- 44:09The patient and body group,
- 44:10on the other hand,
- 44:12was many of the opposite behaviors.
- 44:14So they invited the patient to contribute.
- 44:16They asked them to tell part of their story.
- 44:18They asked them if the story was correct.
- 44:20They asked them to explain or describe
- 44:23their experience being examined.
- 44:24They avoided or at least explained,
- 44:28medical jargon and terminology,
- 44:29and they included the patient non verbally.
- 44:31They surrounded the bedside.
- 44:33They formed almost a circle with the
- 44:35patient at the head of the circle,
- 44:37and so the patient felt as if
- 44:39they were part of the encounter.
- 44:41Obviously,
- 44:41you know which one is more effective.
- 44:43I think that is not the point of the study.
- 44:44But the point is it's really
- 44:48easy to drift toward patient as
- 44:50body when you're busy,
- 44:51when things are complicated,
- 44:53when the diagnosis is difficult or you
- 44:57feel awkward or anxious about teaching.
- 45:00So really paying attention to your behaviors,
- 45:03setting someone up to monitor these
- 45:05behaviors and remind the team to include
- 45:08the patient can be really effective.
- 45:10And that can be a role that
- 45:11you give to the learners,
- 45:12which then has the extra benefit
- 45:14of teaching them how to be good
- 45:17bedside teachers when they step
- 45:18into those shoes down the line.
- 45:21So once you've executed good bedside
- 45:23teaching in a patient centered way,
- 45:25then you want to debrief it.
- 45:27So discuss the learner reactions
- 45:28to the patient experience.
- 45:30And again,
- 45:31this can be done outside of the room,
- 45:33but what what do you think
- 45:35the patient got out of that?
- 45:36Did they seem uncomfortable at any point?
- 45:38What could we do better to
- 45:39embody them instead of as body,
- 45:43things like that and then
- 45:45reflect on what you learned?
- 45:47Again, reflection is key,
- 45:48so you have to allow time and guidance
- 45:51and space for that reflection in
- 45:53order for them to solidify and
- 45:55create these abstract concepts
- 45:57and encourage and incorporate
- 45:58them into future activities.
- 46:02So again, this is the dynamic
- 46:03that you're moderating.
- 46:04It's a teacher learner,
- 46:06patient triad.
- 46:07It's both patient centered.
- 46:09It's learner centered.
- 46:11You're watching all these
- 46:12things happen at once, right?
- 46:13And This is why I think bedside teaching
- 46:15is so challenging and so intimidating,
- 46:17but also so beautiful
- 46:18when it comes off well.
- 46:22So we'll drop this hand out in the chat now,
- 46:24but I I made you a quick little
- 46:27reference card for how to do
- 46:30effective bedside teaching.
- 46:32And if you can really pay attention to
- 46:34these steps and this is everything that we
- 46:37just talked about in sort of a table format.
- 46:39So be both learner centered,
- 46:42follow the three steps and you're going
- 46:44to find yourself being a much more
- 46:46effective bedside teacher and also
- 46:48feeling more comfortable doing it.
- 46:51And really we're moving toward
- 46:53that ideal where you're spending,
- 46:55you know, more than half of your
- 46:57time teaching in front of a patient.
- 47:00Now you still have to round,
- 47:01you still have to do all these things,
- 47:02but I think you can really incorporate
- 47:04it more if you're efficient
- 47:06and effective with it.
- 47:08Some additional best practices
- 47:09that may seem obvious,
- 47:10but I just want to kind of cover,
- 47:13introduce the team,
- 47:15introduce yourselves, explain your roles.
- 47:18You know, I'm a medical student,
- 47:19I'm the attending physician.
- 47:20What does attending physician mean?
- 47:22Things like that are really
- 47:24important for the patients.
- 47:25Let them interrupt.
- 47:26Let them stop you.
- 47:28Let learners interrupt too and ask questions.
- 47:31Be a model for how to interact with patients.
- 47:34Sometimes that's the bedside
- 47:36teaching is we're not going to
- 47:38all examine the patient today,
- 47:40but I'm going to model how to.
- 47:42Well, first of all, you can be practical.
- 47:44I'm going to model how to drape the patient.
- 47:45I'm going to model how I listen to the four
- 47:48or five points for cardiac auscultation.
- 47:52Or you can model behaviors so you
- 47:55can model humanistic behaviors.
- 47:57I want to show you how I disclose a
- 48:00difficult diagnosis or I want to show
- 48:02you how I educate a family and a patient
- 48:05at the same time when one is much more
- 48:09you know up to speed on the diagnosis.
- 48:12Give your learners homework.
- 48:14You don't have to teach everything.
- 48:16And remember we said at the beginning
- 48:18self-directed learning is part
- 48:20of learner centered teaching.
- 48:21So really saying you know we
- 48:23learned this today.
- 48:24If you want to learn more,
- 48:25go check out this chapter in Bates physical
- 48:29examination or go check out this study.
- 48:32It was landmark trial on
- 48:34optic thyritis treatments.
- 48:36Pick your pick your poison and then you
- 48:38can follow up later with resources as well.
- 48:40So one thing I like to do this is not
- 48:42really related to bedside teaching
- 48:43but is start an e-mail chain at the
- 48:46beginning of a rotation with everyone
- 48:47on the team and so then you have access
- 48:50to giving them some resources later on,
- 48:52you know here.
- 48:53Hey guys,
- 48:53here's the chapter from my
- 48:55favorite book on this topic.
- 48:57Check it out.
- 48:58And so you can really teach them how to
- 49:00become self-directed learners in that way.
- 49:04I'll close with a quote and then
- 49:06I'll leave some time for questions.
- 49:07Unless everyone, patient included,
- 49:09feels better after the bedside rounds.
- 49:11Those rounds were not successful.
- 49:13So we all want to feel good about what
- 49:15we're doing as bedside teachers and make
- 49:17sure the patient feels good for them.
- 49:19So I'll allow some time for questions.
- 49:21I have two closing slides.
- 49:24This is one we would love to hear
- 49:27what you thought about this session,
- 49:29what you think about the curriculum
- 49:30as a whole and any feedback.
- 49:32So feel free to scan.
- 49:33The QR code is also in the chat,
- 49:36as is the link.
- 49:39Any questions
- 49:44or comments or stories, whatever.
- 49:52I have a question, Jeff. Yeah. Is it
- 49:54ever OK for students to be
- 49:57using personal devices like,
- 49:58you know like a phone to look up
- 50:01something about the condition
- 50:02in in the front of in front of
- 50:05the patient or do you do you
- 50:07steer students away from that?
- 50:10I think it's inevitable.
- 50:12I'm, I'm not a fan of it,
- 50:14but I also think that especially with AI,
- 50:18there's no way around it.
- 50:19So I I do think we have to explain
- 50:20to the patient what we're doing.
- 50:21You know, there's these signs
- 50:23at the bedside that say we may
- 50:25be on our phones and whatever,
- 50:26but I don't think that's the same thing.
- 50:27I think you need if you see it happening,
- 50:29you need to call it out in a way
- 50:31that explains why it's happening.
- 50:33So you know, just so you know,
- 50:35X here is is looking up the generic
- 50:37dosing of your medication so
- 50:38that they can learn it from it.
- 50:40But I I don't prohibit it, you know,
- 50:43probably because I want to do it myself.
- 50:45Sometimes when I need to look up a
- 50:48dosing or remind myself of of something,
- 50:56if I may, there's something very
- 51:00interesting I learned in discussion with
- 51:02a medical anthropologist years ago,
- 51:04which is that he felt 2 defining
- 51:08characteristics of medical
- 51:09caregivers were shame and fear,
- 51:12and caregivers go to great extents to avoid
- 51:16any situation that might provoke that.
- 51:21But what's also interesting is,
- 51:25you know, for example,
- 51:26not knowing what to answer and you
- 51:28touched on that in your presentation,
- 51:30you know, not having a pad answer
- 51:32for everything that's asked.
- 51:35But what I've discovered
- 51:37in teaching and also directly work
- 51:41with patients is that it's a no lose.
- 51:44If you tell your patient, gosh,
- 51:46that's a great question and you know
- 51:49something we're going to get the best
- 51:51and most up to date answer for that.
- 51:53You know, patients will often comment
- 51:55and say wow, that's a good doctor.
- 51:58He admits if he doesn't know and
- 52:01he looks it up that you know.
- 52:04So I just wanted to share that in in case
- 52:08it encourages other people, you know,
- 52:10to recognize it's really a no lose,
- 52:12it's a win win no matter
- 52:15where the chips fall.
- 52:18Yeah. Thank you.
- 52:19I I couldn't agree more.
- 52:21And I think as we talk about modeling,
- 52:24what an opportunity to model
- 52:26how to be a physician in the
- 52:28time of information overload,
- 52:30you're not going to know every answer.
- 52:31And so modeling how to go look for
- 52:33it and it reassure your patient that
- 52:35you're going to find it is really key.
- 52:44I see a comment in the chat, advice for
- 52:46a teaching session that didn't go well,
- 52:48that someone unexpectedly upset the patient.
- 52:50Of course of all apologize.
- 52:51Would you avoid teaching with them
- 52:53in the future? So it's funny.
- 52:55I created scenarios in case we finished
- 52:57early to talk about One was digital devices,
- 53:00and we've covered that.
- 53:00This was one of the other ones.
- 53:02What happens when you unexpectedly upset
- 53:05a patient during a teaching encounter?
- 53:07And there I can imagine many ways
- 53:09where that could happen, right?
- 53:11So if you're teaching the exam and
- 53:13something uncomfortable happens,
- 53:15you hurt them or cause pain.
- 53:18If you are disclosing A diagnosis that you
- 53:21thought they knew about and they didn't,
- 53:23we're discussing it in an offhand way or
- 53:25you just say something that rubs them
- 53:27the wrong way and they get upset about it.
- 53:29I I agree.
- 53:30I think you of course have
- 53:31to apologize in the moment.
- 53:33I think you need to debrief that with
- 53:35the learners after the experience
- 53:37and say what happened here,
- 53:39you know first of all normalize it.
- 53:40This is going to happen even
- 53:42in non teaching encounters.
- 53:43You're going to,
- 53:44you're going to upset patients by accident.
- 53:47And so normalizing that,
- 53:49modeling,
- 53:49reviewing the behavior that you modeled on,
- 53:52how to re establish the relationship
- 53:55with the patient in the room and
- 53:57then getting their feelings about it.
- 54:00Some students may be upset,
- 54:01some may feel that it was, you know,
- 54:04totally justified, the patient's reaction,
- 54:05obviously feel it was unjustified,
- 54:07etcetera.
- 54:07But as creditors put in the chat,
- 54:09modeling humility in the face of
- 54:12all those reactions I think is key.
- 54:14And would I avoid teaching with them?
- 54:16I don't think I would,
- 54:17but I think I would definitely be a little
- 54:20more explicit than my consent the next time,
- 54:23you know, hey, we're back.
- 54:25I know last time didn't go well,
- 54:27but I think it'd be really
- 54:29important for us to do this.
- 54:30Would you be OK with it?
- 54:32I think that's appropriate.
- 54:33I don't think you need to avoid it.
- 54:35If you feel more comfortable avoiding
- 54:37it or the patient says no more,
- 54:38then you're done.
- 54:40But at least asking is really important.
- 54:54While we're in the last
- 54:54couple of minutes here,
- 54:55I'm just going to switch to the last slide,
- 54:57which is a schedule of upcoming
- 55:00events because I know people are
- 55:02going to drop off to get the places.
- 55:03So the next event is Thursday,
- 55:06November 17th and then you'll see
- 55:08there's another one scheduled for Friday,
- 55:10December 1st.
- 55:12And you can see all of the,
- 55:15you can register and see all the
- 55:17information at the QR code on the right.
- 55:22Any last thoughts or comments?
- 55:24I really appreciate all of you participating.
- 55:26I got to say, you know,
- 55:28I'm by no means the master of this.
- 55:31And so I think the hive mind is really the
- 55:34way to go as we develop best practices.
- 55:36So thank you for for humoring me.
- 55:40Or if you're a Marvel fan. The UNI brain.
- 55:43The UNI brain. I love it.
- 55:51All right, well,
- 55:52maybe we'll wrap it there then.
- 55:54Thank you, everybody.
- 55:55Thanks for being here.
- 55:56Thanks for coming to the sessions.
- 55:58Thanks so much. Yeah.