What is Holding us Back: Barriers to Bedside Teaching

Classically, bedside teaching occurred during inpatient ward rounds conducted by academic professors in university teaching hospitals. This environment was a stable one, where patient-centered teaching could be conducted at a calculated pace without interruptions. Unfortunately, in recent years, modern medical education has come to embrace a more didactic format at the expense of bedside teaching for a variety of reasons [3, 4]. Lecture-based curricula are a more easily implemented “passive approach” that requires fewer instructors, less work ethic, and no expectation for “bedside teaching skills.” This didactic approach alleviates instructors’ concerns over the need for an “expert performance” at the bedside and eliminates any unwanted involvement of the patient in discussions about his or her own care, the so-called medical chauvinism. The academic community itself has contributed to this migration by failing to provide faculty development in the critical skill set needed for successful bedside teaching. This is further compounded by the underappreciation of the “value” of accomplished clinician–teachers with regard to promotion and financial support [5, 6]. Finally, time constraints in the ED associated with efficient and effective patient management exert a negative influence on the time spent at the bedside.

Educators can easily overcome these obstacles with some enthusiasm; a little training; a realization that experts can say, “I don’t know”; and a commitment to improving health care in general. Bedside teaching improves everyone it touches, including patients, even if they are not the intended target. The overwhelming majority of patients feel educated and reassured about their illness and their diagnostic and therapeutic plans and appreciate the opportunity to get their questions answered. The impact of direct observation during bedside encounters cannot be understated. Direct observation can positively affect not only history and physical examination skills but procedural ability, professionalism, interpersonal skills, and communication as well [7, 8]. Linking teaching with a visual cue (the patient) is a very powerful tool that can improve the quality of care provided by the entire health care team. Successful bedside teaching does require some planning and utilization of several attributes and skills that anyone can develop.

The Basics: Characteristics of Effective Bedside Teachers

Until Bandiera et al published their study in 2005 [9], characteristics for effective bedside teaching in the ED were adapted primarily from other practice environments. The personality characteristics of the best teachers are well known: enthusiasm, availability, knowledge, confidence, receptivity, and inquisitiveness (Table 5.1). Unfortunately, personality alone does not guarantee learner success. Heidenreich et al. [10] and Bandiera et al. [9] examined effective and efficient strategies for teaching in the ambulatory and ED settings, respectively (Table 5.2). A combination of the right personality traits and some easily learned and implemented learning strategies results in successful bedside teaching.

Table 5.1 Characteristics of an excellent bedside teacher.

Enthusiastic

Available, approachable, patient, calm, respectful, tolerates errors

Excellent listener

Seeks out learner’s goals (learner centered)

Knowledgeable but realistic and willing to say, “I don’t know. Let’s find out.”

Actively seeks opportunities to teach

Role model for professionalism, communication, and interpersonal skills, lifelong learning

Effective, efficient, and timely

Data from [9, 10].

Table 5.2 Strategies for effective ED teaching.

Orient the learner by relaying clearly defined expectations of his or her performance

Optimize faculty–learner interaction using optimal interpersonal skills and teaching tools such as the Internet, teaching files, and prepared cases

Provide a clear, concise, focused message (“teaching bite”) and avoid “overteaching”

Provide learner-centered instructions that are prioritized and tailored to the learner’s needs

Promote learner autonomy and facilitate active problem-solving and critical thinking skills through teacher–learner reflection

Teach in the patient’s presence and mentors and reinforce effective behaviors (reflective modeling)

Demonstrate examination and procedural skills with clarity

Improve the environment by ensuring adequate time to teach without interruptions

Provide effective, prompt feedback

Data from [9, 10].

Success begins with enthusiasm and a desire to positively influence the learner. Excellent teachers seek opportunities to teach and share cases even with learners they are not supervising. They plan ahead, developing and utilizing teaching resources to augment their clinical-based instruction. These resources may include case files; electronic depositories of clinical photos, radiographs, electrocardiograms, and research articles; and Web-based teaching sites. They employ and encourage effective interpersonal and communication skills to establish a receptive learning environment and project a supportive, approachable, calm demeanor.

As the shift begins, get to know the learner and ascertain his or her educational needs and focus for the shift. Learner-centered instruction is the single most commonly cited effective learning strategy by EM educators [9]. Relay upfront clear expectations for learner performance. Foster a collegial atmosphere that encourages an open exchange of ideas. This requires being an active listener; teachers should listen more and talk less. Ask questions that promote learner autonomy, critical thinking, problem-solving, and linking of new elements to the learners’ existing fund of knowledge. Ask the learners to commit to their ideas and allow them to make mistakes; this provides an excellent framework for discussion and feedback. Allow time and opportunity for the learner’s self-assessment and reflection. Be knowledgeable but realistic and willing to say “I don’t know. Let’s find out.” Teach how to search for the best evidence and apply it to patient care in real time (knowledge translation). This is a critical facet of mentoring lifelong learning.

Recognize and seize the teachable moment; every case can provide a teaching point. Be creative. When faced with a clinically common or unchallenging case, change the age, alter the setting to a community hospital with fewer resources, or throw in a hypothetical “curveball” laboratory or clinical finding. Deliver a clear, concise, focused message (“teaching bite”) at the learner’s level that ensures his or her reception. Avoid “overteaching” or providing an excessive amount of information that obscures or clutters the intended teaching point. If you provide more than one teaching point, provide a summary at the end of your discussion.

Unfortunately, even the most enthusiastic, skilled, well-intentioned teachers are often thwarted in their efforts by “environmental issues.” Frequent interruptions, a full waiting room, and competing demands on a busy clinical shift all conspire to negate effective learning. Sometimes just finding a quiet place to discuss a case is nearly impossible. Academic faculty must proactively “design” an environment conducive to learning. This begins by ensuring faculty and departmental buy-in by including the provision of quality education in the department’s mission statement. Thus, implementation of “solutions” is supported by a collective mandate. Many academic EM departments practice the “teach-only” attending approach, whereby one faculty’s sole purpose on each shift is to teach and evaluate [8]. Others employ “uninterrupted teaching rounds,” in which they share teaching points from all patients in the ED at the beginning or end of each shift, with only critical interruptions from the ED staff allowed. Most departments have purposely designed “team areas” where cases can be discussed while maintaining patient privacy. Ultimately, the best place for teaching to take place is still at the bedside.

The Framework: The Experience versus Explanation Cycle

Enthusiasm and interactive educational skills that enhance active learning and aid the learner in developing critical thinking skills constitute only half the battle. Cox noted that bedside teaching requires developing a framework in advance so that the educational experience will follow. This framework can be divided into two connected cycles: the experience cycle (with its phases of preparation, briefing, clinical experience, and debriefing) and the explanation cycle [11, 12].

Preparation begins with determination of the needs of the teacher and the learner and communicates expectations for the educational encounter. Teachers must recognize the inherent limitations and set appropriate, limited goals for each encounter. Before starting the experience cycle, answer the simple question, what would everyone like to accomplish? This is also the phase during which resources are identified and developed (classic articles, websites, PDA resources, departmental intranet teaching files).

The briefing phase prepares both the patient and the learner for the clinical encounter. It consists of an introduction and an explanation of the purpose of the bedside encounter, a discussion of the ground rules with the learner, and a review of the examinations or procedures that might be performed. The actual clinical encounter provides an excellent opportunity to mentor the performance of history taking and physical examination, demonstrate physical examination findings and procedures, model patient interaction skills, guide and develop critical thinking skills, and provide feedback. As learners become more advanced in their clinical experience and skill set, teachers, by design, should allow the learner more autonomy and responsibility with regard to diagnostic and therapeutic decision making. The hallmark of an excellent teacher is allowing the exact right amount of learner autonomy while covertly observing patient care to prevent medical error.

The bedside encounter is also a superb opportunity to enlighten patients about their disease process. It provides a chance to explain what testing and therapeutic procedures will be performed and to reinforce and educate them about your plans for treatment and follow-up after discharge. The experience cycle ends with the debriefing phase, which gives the learner an opportunity to answer any “sensitive questions” not raised in front of the patient. The teacher reviews what was learned at the bedside, ensures that the learner received the correct learning points, provides constructive feedback, and devises plans for future encounters.

The explanation cycle begins with reflection and is followed by explication, working knowledge, and preparation for future patients. Reflection allows the teacher and the student to link practice with theory and previous experiences or knowledge, whereas explication examines how medical practice can be improved by advances in biomedical science or current best evidence (practice-based learning). This links the clinical experience with theory and research relevant to the case and brings evidence-based medicine to the bedside by providing an opportunity to assign clinical questions that the learners can use to develop lifelong learning skills and spark future offline learning. The explanation cycle concludes with the “working knowledge” phase, which extracts and solidifies practical knowledge from the clinical experience that can be applied to future encounters.

Several other accepted frameworks are employed to guide bedside teaching. One of the most popular, efficient, and validated methods is the five-step microskills model of clinical teaching, also known as the One-Minute Preceptor [13, 14]. In a hectic ED, this model provides a condensed version of the aforementioned experience/explanation cycle model and incorporates many of the effective learning strategies identified by Bandiera and associates [9]. The basic steps are to (i) get a commitment, (ii) probe for supporting evidence, (iii) discuss a teaching pearl, (iv) reinforce what was done right, and (v) correct mistakes. Studies show that this method enhances faculty confidence in learner assessment, improves learner diagnostic accuracy, and results in a more effective, efficient, and desired teaching encounter [14, 15]. Another method employs the six-step learner-centered technique known by the acronym SNAPPS—Summarize history and findings, Narrow the differential, Analyze the differential, Probe preceptor about uncertainties, Plan management, and Select case-related issues for self-study [16, 17]. The SNAPPS format takes the learner beyond the role of “factual reporter” and into the critical thinking role of “synthesizer” by enhancing expression of diagnostic reasoning and uncertainties. These and other methods are discussed further in other chapters.

Implementation: The Art of Bedside Questioning

Bedside teaching should be an interactive session that maintains active learner participation. Passive learning occurs when teachers talk too much, ask close-ended questions, or answer their own questions. Passive learning not only is ineffective and inefficient but also conveys the assumption that the learners are disinterested. Envision yourself as a coach and a facilitator who promotes critical thinking by the student. Teaching critical thinking skills will have more of a lasting impact on learners than other methods, such as “pimping” (asking learners obscure medical questions to see how much they know or do not know). When skillfully asked, questions should assist the learners in identifying relationships and linking the unknown to the known. Formulate questions that stimulate the teacher and the student to explore ideas and solutions together. One simple method that can be implemented is known as the five whys. Borrowed from a method used to assist with root-cause analyses, the “five whys” is a simple question-asking technique that explores the cause-and-effect relationship underlying problems, whereby the “next why” is based on the previous answer. Expert clinical teachers may employ “guiding questions” to make the learner focused, promote understanding, probe their reasoning, crystallize an idea, or challenge a conclusion (without confrontation) (Table 5.3) [18]. These questions focus on synthesis and interpretation of knowledge as opposed to a simple recall of facts. The aforementioned SNAPPS method is a perfect example of this process. It encourages learners to commit to and express their diagnostic reasoning as well as uncertainties about the case. This lays an incredibly fertile foundation for the development of critical thinking skills as facilitated by the teacher. In addition, seeking a commitment from the learner allows more focused and effective behavior-changing feedback.

Table 5.3 High-yield questions (focus, probe, prompt, challenge).

Why do you believe that to be true?

What have you learned so far?

How did you reach that conclusion?

What is your reasoning behind that question?

What led you to that decision?

What are some other possibilities that would explain that presentation?

Why is that information important?

Why is one approach better than another? Are there other approaches that have not been considered?

What will happen if you do/do not do X or Y?

What is the association between those two findings?

Data from [11].

Clearly, the style in which questions are asked has a tremendous impact on the learner’s perception of a positive or a negative learning climate. Questions that are unexpected, confrontational, accusatory, or used to make a student feel bad create a negative environment and hinder learning. This is also true of teachers who exhibit negative body language, ask “rapid-fire” questions, or continually interrupt their student’s answers.

In contradistinction, teachers who seek to develop critical thinking and successful learning ask meaningful, probing questions in a nonthreatening, positive climate. Their questions stimulate and challenge learners to analyze, solve problems, and think independently [19]. This interactive collegial discussion should be followed immediately by formative feedback. Adjectives applied to effective formative feedback include timely, relevant, descriptive, verifiable, focused, and constructive. The exchange should include both positive and negative reinforcements. A commonly cited method is the “Sackett Sandwich” (positive-negative-positive). Finally, the “art” of questioning allows teachers to convey their interests, spread their enthusiasm, and continue their own lifelong learning.

As teachers, the types of questions we ask determine the level of intellectual challenge for the learner. Convergent or close-ended questions require little critical thinking, whereas probing questions require independent assessment, critical analysis, and problem-solving skills. A blend of convergent, divergent, and probing questions will make bedside teaching an active, challenging process. On average, instructors wait only 2–3 s after asking a question before answering it themselves. Studies have shown that the optimal wait time is actually 17 s. Although this seems like an eternity, teachers must recognize variables that influence expert–novice interactions.

Be cognizant of the fact that expert and novice thought processes take very different pathways through the brain. Experts jump from A→E quickly with little conscious thought process in between; novices think more concretely in a stepwise A→B→C→D→E process that is much slower. For this reason, experts who have long forgotten the drawn out stepwise links have a difficult time explaining their thought process and conclusions to novices. Consider the descriptors in Table 5.4 for the novice versus expert thought process.

Table 5.4 Characteristics of Novice versus Expert Thought Process.

	Novice	Expert
Knowledge of subject	Sparse	Detailed
Experience	Limited	Extensive
Pattern recognition	Slow	Rapid
Memory	Isolated facts	Concepts

Experts in bedside teaching recognize this processing gap and take time to explain their thought process and decision making in a stepwise point-to-point fashion [20].

Closure: Effective Feedback as It Relates to Bedside Teaching

The bedside experience should end with effective, formative feedback. Many researchers have demonstrated that consistent, objective, and timely feedback on performance is the educational intervention that is most likely to produce a meaningful change in the behavior of professional trainees [21]. Yet, errors are repeated 70% of the time after feedback is provided. Students have poor recall of the “corrective” message in postencounter feedback. Feedback is rarely provided to physicians-in-training, nurses, or prehospital care providers: less than 10% of interactions between students/residents and patients are followed by feedback, and less than 20 s of the average 4-min “teaching” encounter in clinical settings is used to provide formative feedback [22]. Finally, students and faculty have different perceptions about what should be included in feedback.

Feedback is the backbone of formative evaluation and should occur continually in clinical teaching. It is real-time “coaching” that occurs in the immediate proximity of the action or behavior being observed. When delivered correctly, it is the most effective tool for reinforcing good behaviors and extinguishing negative ones. This sounds so easy and straightforward: how do we fail?

Unfortunately, first and foremost, teachers were never taught how to give effective feedback. Feedback commonly lacked a vital component, thus rendering it ineffective. Criteria used to define effective feedback include its objectivity, consistency, timeliness, relevance, and clarity. It should be descriptive, verifiable, and focused enough to have a defined impact on the learner (Table 5.5).

Table 5.5 Feedback tips.

Allow eslf-evaluation initially

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