By: Carl Preiksaitis (@CMPreik)
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” -Sir William Osler
Navigating the Challenges of Bedside Teaching in Modern Times
Bedside teaching is becoming a lost art. Increasing time constraints, attention demanded by the electronic health record, and, more recently, concerns about COVID transmission are all likely contributing factors to this decline.
The move away from this teaching practice has led to a reevaluation of its utility in the current clinical environment, with advocates on both sides. A systematic review of bedside rounds by Ratelle et al. published in 2022 found mixed results for improving learners’ knowledge and skills but benefits to learner behavior and health care delivery in clinical learning environments. The authors recommend that moving forward, educators should consider the contextual factors, “when, how, and why do bedside rounds work?”
Learning science may offer a roadmap to more effective bedside teaching.
The Institute of Educational Sciences, the research arm of the U.S. Department of Education, identified six proven practices that promote learning for all students, regardless of grade or subject. These practices are supported by learning science research, and they have been used successfully in medical education:
- Spaced Practice
- Retrieval Practice
- Concrete Examples
- (Dual Coding
I propose these six practices can serve as a conceptual model to explain why bedside teaching is productive. The model may then be used to develop more efficient approaches to bedside teaching or determine why some bedside teaching approaches may be ineffective for some learners.
Charting the Course: Applying the Six Proven Practices to Bedside Teaching
Breaking learning into smaller sessions, rather than cramming, allows for better retention. Bedside teaching can be viewed as a series of spaced practice sessions, where learners can apply and reinforce their knowledge over time. For example, a medical student may learn about the presentation and management of heart failure in a lecture or textbook, then apply this knowledge at the bedside of a patient with swollen extremities and shortness of breath. By encountering and discussing similar cases multiple times throughout their clinical rotations, learners solidify their understanding of heart failure and its management. Spaced practice also helps students avoid burnout and cognitive overload, as they can gradually build on their knowledge base rather than trying to absorb vast amounts of information in a short period.
Actively recalling information from memory improves neural connections. Bedside teaching encourages learners to recall pertinent information about patients and apply their knowledge in real-time. For instance, when discussing a patient’s case at the bedside, the attending physician can ask targeted questions to prompt learners to recall specific information, reinforcing memory and understanding. Recognizing elements of a patient’s presentation that are characteristic of a particular disease process (the appearance of a patient with a kidney stone, the vesicular rash of zoster, or a patient with Bell’s palsy) forces the recall of similar patient presentations, again enhancing these connections.
Explaining concepts in one’s own words and connecting new information to existing knowledge enhances understanding. Bedside teaching allows learners to verbalize their thought processes and explain the reasoning behind their differentials or plans to others at the bedside. By sharing their thinking, learners will solidify their understandings of a disease process, while also making connections to previous cases they have encountered. Comparing and contrasting cases is also a powerful technique to encourage learners to connect new information to existing knowledge.
Mixing different topics or skills within a learning session enhances retention. Bedside teaching naturally lends itself to interleaving, as learners encounter a variety of clinical scenarios and must apply various skills and knowledge. A single bedside teaching session might involve discussing patients with diverse medical conditions, requiring the learner to switch between different topics and skillsets. This process helps learners develop cognitive flexibility, as they can adapt to new situations and integrate knowledge from different domains. For instance, switching between a discussion of a patient with pneumonia and a patient with diabetic ketoacidosis requires the learner to apply different pathophysiological concepts and management strategies.
Providing tangible examples or analogies helps learners grasp abstract concepts. Bedside teaching provides real-life examples of patients’ conditions, which can solidify understanding. For example, demonstrating a delayed capillary refill can solidify the idea of decreased perfusion in cardiogenic shock. Furthermore, there are many disease presentations that initially seem abstract when reviewed in a textbook, but are unforgettable in the clinical setting, like seeing Kussmaul breathing, feeling palpable purpura, or smelling melena.
Combining multisensory information enhances retention. Bedside teaching offers opportunities to integrate verbal explanations and discussions with the sights, smells, and sounds of real patients. For example, during bedside rounds for a patient with suspected stroke, the educator may review the patient’s brain imaging with the learners, discussing the findings and correlating them with the patient’s clinical presentation. This integration of visual and verbal information helps learners create a more robust mental representation of the condition, improving their ability to recall and apply this knowledge in future clinical situations.
The six proven practices identified by the Institute of Educational Sciences provide a framework for understanding the effectiveness of bedside teaching in medical education. By incorporating these practices into bedside teaching, medical educators can enhance learning experiences for their students and navigate the challenges of modern clinical environments. As Sir William Osler aptly noted, the combination of theoretical knowledge and practical application is crucial for sailing the seas of medical education, and bedside teaching remains a valuable vessel in this journey.
About the Author: Carl Preiksaitis, MD is an emergency physician and medical education researcher who practices in Palo Alto, CA. He is currently a first-year Medical Education Scholarship Fellow in the Department of Emergency Medicine at Stanford University. Twitter: @CMPreik
ABOUT THE EDITOR: MICHAEL A. GISONDI, MD (HE/HIM/HIS) IS A MEDICAL EDUCATION RESEARCHER WHO LIVES IN PALO ALTO, CALIFORNIA. MICHAEL CURRENTLY SERVES AS ASSOCIATE PROFESSOR AND VICE CHAIR OF EDUCATION IN THE DEPARTMENT OF EMERGENCY MEDICINE AT STANFORD UNIVERSITY. TWITTER: @MIKEGISONDI
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2. Ratelle JT, CN Gallagher, AP Sawatsky, et al. The Effect of Bedside Rounds on Learning Outcomes in Medical Education: A Systematic Review. Acad Med. 2022;97(6):923-930.
3. Pomerance L, J Greenberg & K Walsh. Learning about learning: What every teacher needs to know. National Council on Teacher Quality. https://www.nctq.org/publications/Learning-About-Learning:-What-Every-New-Teacher-Needs-to-Know . January 2016.
4. Smith M and Weinstein Y. Six Strategies for Effective Learning. The Learning Scientists Blog. https://www.learningscientists.org/blog/2016/8/18-1 August 18, 2016.
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