Teaching clinical learners at the patient bedside has declined over the last couple of decades, yet many teachers and learners acknowledge the value of clinical skills in patient care. To return clinical teaching to the bedside, faculty development is essential, the relevance of bedside skills emphasized and challenges of the modern clinical environment acknowledged and addressed.
“In what may be called the natural method of teaching, the student begins with the patient, continues with the patient and ends his study with the patient, using books and lectures as tools, as means to an end. For the junior student in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself.” (Sir William Osler, Address to the New York Academy of Medicine, 1903).
When I reflect on clinical education, the mental picture always consists of patient rooms, master clinicians and numerous trainees jockeying for space to better hear the professorial pearls. My patient examination is carried out to the rhythmic beat of “inspection, palpation, percussion, auscultation”, a rhythm embedded into my cerebral hemispheres since early training days.
Yet, over the last decade I have witnessed patient discussions occurring more and more along impersonal corridors and conference rooms, case histories and diagnostic plans written before patients are admitted after thorough electronic biopsies. As a direct contradiction of Osler’s quote above, “Medicine has moved from a procession of young trainees briskly trailing a revered clinician, who interviews and examines patients, questions quaking trainees, and makes sacred diagnostic pronouncements, to teams that inspect a computer screen, palpate the keyboard, percuss a mouse, and auscultate over textile barriers without any expectation of seeing, feeling, or hearing” (Ramani and Orlander 2013).
While clinical teachers, young and mature, espouse the values of patient-centred education; the patient’s bedside now largely resembles uncharted territory (Verghese 2008). A few months ago when I attended on the inpatient medicine service, I heard a nurse inform the resident that a patient was short of breath. The resident, intern and a medical student spent a quarter of an hour outside the patient room, reviewing the vital signs, electronic records and debating why the patient might be short of breath with the nurse in the background resembling a cat on a hot tin roof. She could not comprehend the new method of patient assessment which clearly did not include going to the bedside immediately. They were still there when I slipped in, examined the patient, slipped out and informed the team of my diagnostic impression. While I reckoned I would be inspiring the young to move to the bedside, all that happened was that they were ready to accept my diagnosis and move on to other weightier matters.
As clinical neurologists often question, “where is the lesion”, I now ask the same question of bedside teaching. The barriers to bedside teaching are increasing with increasing documentation requirements and reliance on technology today (Ramani et al 2003, Ramani and Orlander 2013), but I argue that quality time spent at the bedside will be time well spent. Although time is often quoted as a barrier to bedside examination and teaching and technology is perceived as the magic wand which will solve all diagnostic dilemmas, studies have demonstrated that a skilled history and physical examination are important contributors to accurate diagnoses (Peterson et al 1992). The bedside teaches more than history taking and physical examination. Demonstrating communication skills, teaching humanistic aspects of clinical medicine, and role modelling professional behaviours are some essential elements of education for good patient care that cannot be effectively accomplished in a classroom (Ramani et al 2003).
In an era of cost consciousness in health care, we cannot continue to order investigations indiscriminately hoping that technology will provide all the answers that our special senses fail to perceive. In fact, without the clinical context technology can also discover unrelated and insignificant lesions that lead physicians to chase diagnoses with more investigations leading to the tail wagging the dog.
Patients still expect physicians to talk to them and touch them (Verghese et al 2011). While for some, the CT scan is like the all-seeing “Eye of Sauron”, for most patients the stethoscope is the “All-hearing Ear” that reveals the truth behind all ailments. Recently, a patient requested a new primary care physician and was booked to see me. Before discussing his medical problems, he informed me that he had requested to see a different physician because the stethoscope displayed prominently around his previous physician’s neck remained unused during all their consultations.
To promote effective bedside teaching, some key factors need to be addressed. Learners need to know why they should spend time at the bedside and how it matters in their world of patient care. The days when hours could be spent on head to toe examination waxing eloquent on possible differential diagnoses at the bedside are long gone. The current environment calls for efficiency in bedside skills and emphasizing its relevance. Younger faculty do not feel comfortable teaching at the bedside and lack confidence in their own clinical skills. Faculty development is essential to increase and improve bedside teaching and needs to address development of teachers’ clinical skills as well as teaching skills. Finally, the culture of academic institutions needs be one where astute clinical skills are valued and teaching these skills revered.
In the end, “The good physician treats the disease; the great physician treats the patient who has the disease”—Sir William Osler.
1. Peterson MC, Holbrook JH, Von Hales D, Smith NL, Staker LV. Contributions of the history, physical examination, and laboratory investigation in making clinical diagnoses. Western Journal of Medicine 1992;156:163–5.
2. Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Academic Medicine 2003;78:384–90.
3. Ramani S and Orlander JD. Human Dimensions in Bedside Teaching: Focus group discussions of Teachers and Learners. Teaching and Learning in Medicine, 25(4), 312–318.
4. Verghese A. Culture shock-patient as icon, icon as patient. New England Journal of Medicine 2008;359:2748–51.
5. Verghese A, Brady E, Kapur CC, Horwitz RI. The bedside evaluation: Ritual and reason. Annals of Internal Medicine 2011;155:550–3