Teaching in medical school has thankfully and quite rightly changed. Gone are the days when a consultant in a three piece suit, bow tie, and braces would float from bed to bed, without any discussion or consent, pointing out painful and disfiguring pathologies on traumatised patients, and only revealing the eponymous syndrome after 17 anxious, but eager medical students had, with trembling hand, fully demarcated the extent of the disease. There are of course obvious disadvantages with this method. Most importantly the patient feels degraded, isolated, and no more informed about their condition. This being said there are huge advantages, and a similar “bedside teaching” as described above still occurs with great effect in less economically developed countries. This has been witnessed by myself, with discomfort, on a recent trip to Africa.
Bedside teaching is without question the best way to learn examination technique, communication skills, and disease pattern. Textbooks and recreation in moulage is improving, but will never cement the knowledge of a disease and management in the same way as seeing the manifestation of pathology in signs and symptoms. A study in 2001 compared the ability of junior doctors of comparable level in the UK, Canada, and the US to identify a variety of heart murmurs. The study found Canada had significantly better results and there was a direct correlation with the amount of teaching time at the bedside. [1] A thorough history and examination have been shown to provide the correct diagnosis in as much as 90% of cases. [2]
Bedside teaching is most certainly dying, or at least has taken a severe beating. Less than half of doctors feel they received enough of it. Current estimates show that the medical course comprises 8-19% bedside teaching. [3,4] This compares meekly with 75% in the 1960s. Tremonti’s analysis showed median time spent at bedside per day was 2.5 minutes with 69 spent in the classroom. [5] This is clearly not enough.
We have to ask ourselves: “why is this happening?” I am going to offer my top three reasons. These are not the only ones and I urge you to think of your own so you can challenge them.
- Teaching with this size group (usually less than 6) is incredibly labour intensive. Preparation is arduous. There is a period beforehand of scrabbling around to find patients who are suitably conscious, willing, and informative. Alternatively, if you are on the wards and know the patients there is a scramble to find students who are present, free, and available at those sporadic times that you can spare. Your time is precious: free time to teach is unpredictable and fleeting. The time spent teaching students teaching invariably ends up as less than the organisational time. This is frustrating and certainly creates a mental and physical barrier to teaching.
- Patients are dynamic: admitted, discharged, moved ward, sent for imaging, and taken to theatre before you have even had the time to find students and teach them. When you do find students it is during protected meal times, or family are visiting, or your workload increases. If you are attempting to demonstrate clinical skills you will be delaying diagnostic or therapeutic interventions to await students to come and observe, which is not clinically sound and postpones key decision making.
- Doctors feel they are burdening and upsetting the patient by having multiple people examine them often multiple times a day. On the whole, this is a myth. Patients report increased satisfaction after bedside teaching with a greater understanding of their disease and a break in the monotony of the ward. In fact, around 80% of patients say that they enjoy bedside teaching (6). This shows that when teaching is done in a respectful manner, allowing the patient to ask questions and discuss any problems it can be a useful tool in further evaluating the patient and establishing fundamental rapport and trust.
Students are out there somewhere, standing sheepishly in the corner of an operating theatre looking at the back of an ENT surgeon perform a panendoscopy and pretending they can see the vocal cord lesion. They are desperate to learn in a non-threatening but real life environment. Unfortunately opportunities to develop as students, doctors, and teachers are being missed for reasons that are baseless and easily challenged. We are worse doctors for it and students are more and more dissatisfied.
Mark Mikhail is a junior doctor. He is part of the NHS England Clinical Entrepreneur Programme.
Competing interests: None declared.
References:
(1) Mangione S. Cardiac auscultatory skills of physicians-in-training: a comparison of three English-speaking countries. The American journal of medicine. 2001 Feb 15;110(3):210-6.
(2) Sandler G. The importance of the history in the medical clinic and the cost of unnecessary tests. American heart journal. 1980 Dec 31;100(6):928-31.
(3) Crumlish CM, Yialamas MA, McMahon GT. Quantification of bedside teaching by an academic hospitalist group. Journal of hospital medicine. 2009 May 1;4(5):304-7.
(4) LaCombe MA. On bedside teaching. Annals of Internal Medicine. 1997 Feb 1;126(3):217-20.
(5) Tremonti LP, Biddle WB. Teaching behaviors of residents and faculty members. Academic Medicine. 1982 Nov 1;57(11):854-9.
(6) Wang-Cheng RM, Barnas GP, Sigmann P, Riendl PA, Young MJ. Bedside case presentations. Journal of General Internal Medicine. 1989 Jul 1;4(4):284-7.