Reflections from the Liminal Space: Teaching III – In the Ward

(This is a three part series that will run consecutively.  Click here for Part 1 and Click here for Part 2.  Michelle (a Maternal Fetal Medicine specialist), Tim (an intensivist) and Mary (a pediatric gastroenterologist) are just finishing the Royal College diploma in medical education offered at McMaster University.  More details here. -Jonathan (@sherbino))

By Mary Zachos (@maryz777)

The Core

Teaching at the bedside (ward) is a fundamental part of medical training throughout the years.  Learners believe that although bedside teaching is underutilized, it is necessary for learning essential clinical knowledge and skills.¹ Learners find value in learning skills including physician-patient communication, physical examination, clinical reasoning and professionalism.

Bedside teaching is an excellent opportunity for clinical teachers to assist learners to construct and utilize new knowledge and information.  We know from adult learning principles and the constructivist learning theory that learners enter new situations with pre-existing knowledge and preconceived ideas based on their prior experiences.  Such encounters provide opportunity for the motivated and self-directed learner to construct new knowledge and improve their existing understanding in a relevant and pragmatic manner.

Social constructivism states that learning is socially situated and knowledge is created through interactions with others.  With bedside teaching, this necessitates the involvement of the learner with other learners, with a clinical teacher and the patient.  It is important for the teacher to assess learners’ prior experiences and motivations in order to understand their pre-existing knowledge so that planned clinical encounters are more meaningful.  Learners are interested in focusing their learning on the problems of the patient in front of them, instead of learning about unrelated topics.  Such opportunities enable learners to either assimilate new information with their preconceived ideas or to adjust their pre-existing knowledge in order to accommodate it.  The more often the learner engages in this type of learning, the quicker she/he will develop expertise in topic areas.

The Dreyfus model of skill acquisition explains how learners acquire clinical skills and become more competent as they progress through stages (from novice to master).²  Increasing expertise is characterized by the ability to acquire and store new knowledge and information into logical frameworks that have patterns.³

Metacognitive skills are an important attribute seen in successful learners that can progress throughout such stages.⁴ This skill involves an individual planning how he/she will think about an activity even before starting it, monitoring his/her thinking during the activity, and evaluating this thinking after it is completed.

Teachers can assist their learners in developing metacognitive skills by discussing aspects of a patient’s case before approaching the patient’s bedside.  This pre-planning can aid the learner to reflect upon his or her own ideas in the midst of the bedside teaching encounter. The ability to self-reflect requires practice and can readily be incorporated into feedback in a meaningful way.

Students often believe that bedside teaching is underutilized for multiple reasons, including lack of initiative, lack of teaching skills or knowledge, lack of patient cooperation, learner desire for autonomy, learner fear of embarrassment, lack of time or competing responsibilities, lack of expectations, and devaluation of clinical skills in favour of reliance on technology.  However, there are strategies that can optimize bedside teaching.

Patients are unafraid and often welcoming of students when they are oriented to the intent and goals of bedside teaching.⁶ Not only is it ethically appropriate, but by asking them ahead of time, patients have the opportunity to have more control over their course in hospital and understand what to expect from the encounter.  All of us have time constraints and competing responsibilities on a daily basis.  This can be overcome by maintaining flexibility and selectivity of patient cases that have high educational yield for learners while integrating it into daily clinical duties.  Learners must also be reassured that they will still have autonomy which can be incorporated into the teaching process.  This can be achieved when learners are simply “asked” rather than being “told” what to do.³ At the same time, organizations must continue with faculty development to reinforce appropriate attitudes, knowledge and skills for clinical teaching.¹

In particular, more focused teaching models can be applied throughout this process so that effective and efficient bedside teaching occurs.  The SNAPPS⁷ and one-minute preceptor models⁸ are two examples of such models of teaching that can be utilized at the bedside.

SNAPPS

• Summarize the case
• Narrow the differential (to 2-3)
• Analyze the differential (compare / contrast possibilities)
• Probe the preceptor (ask questions)
• Plan management (for patient’s issues)
• Select an issue for self directed learning)

Microskills Model (“One minute preceptor”)

• Get a commitment
• Probe for supporting evidence
• Teach general rules
• Reinforce what was right
• Correct mistakes.

Both SNAPPS and one-minute preceptor models were developed to improve traditional clinical teaching methods and designed in accordance with learning theory to be time-efficient and learner-centred.  Learner centred teaching models is known to improve trainees’ educational experiences in outpatient setting.

The Denouement

William Osler stated “[She] who studies medicine without books sails an uncharted sea, but [she] who studies medicine without patients does not go to sea at all”, in addition to “Listen to your patient, he is telling you the diagnosis”.

Teaching with the involvement of patients can be rewarding and beneficial to everyone.  As we enter the era of competency based medical education, it is important now more than ever to shift our thinking of bedside teaching as an informal tool of sharing knowledge and skills but to a formal model that emphasizes the observable abilities that learners must acquire during their medical training.

References

1. Williams KN, Ramana S, Fraser B, Orlander JD. Improving bedside teaching: findings from a focus group study of learners. Acad Med. 2008;83(3):257-64
2. Batalden P, Leach D, Swing S, Dreyfus H, Dreyfus S. General competencies and accreditation in graduate medical education. Health Aff (Millwood). 2002;21(5):103-111.
3. Carraccio CL, Benson BJ, Nixon LJ. From the educational bench to the clinical bedside: translating the Dreyfus developmental model to the learning of clinical skills. Acad Med.2008;83(8):761-7
4. Quirk M. Intuition and Metacognition in Medical Education. Keys to Developing Expertise. Springer Publishing Company. 2006
5. Stickrath C, Aavgaard E, Anderson M. MiPLAN: a learner-centered model for bedside teaching in today’s academic medical centers. Acad Med 2013;88(3):322-327.
6. Lehmann LS, Brancati FL, Chen M, Roter D, Dobs AS. The effect of bedside case presentations on patients’ perceptions of their medical care. N Engl J Med 1997;336(16):1150-5.
7. Wolpaw T. SNAPPS: a learner-centered model for outpatient education.Acad Med 2003:78(9):893-8.
8. Neher JO, Gordon KC, Meyer B, Stevens N. A five-step “microskills”model of clinical teaching. J Am Board Fam Pract 1992;5(4):419–424

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Thank you to our editor, Teresa Chan (@TChanMD), for recruiting Mary for this article!

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