1 How Has the Concept of Bedside Teaching Evolved?

The patient’s bedside has been compared to a platform where budding doctors get an opportunity to actively engage, learn, and acquire new skills. It provides the best in-person professional environment for young medical graduates, staff physicians, and fellows to translate their theoretical knowledge into practical skills. The concept of human learning has been based on the evolution of varying theories of behaviourism, cognitivism, and constructivism [1]. Human psychology trains itself by constructive analysis of the varying experiences in day-to-day learning; in other words, exploring old information through the discovery of new information. This phenomenon has been termed as the ‘spiral learning’ by Bruner [2] a concept that is reinforced in bedside teaching. This emphasizes active participation in teaching by the mentee/learner, which is the ‘new normal’ for a didactic teaching format (Fig. 39.1). The importance of bedside teaching dates back to the fifteenth century, when Sylvius (1614–1672), a renowned French practitioner, voiced his thoughts on teaching on rounds [3]. He believed in the concept of daily teaching by asking questions about the various clinical signs and symptoms and inquiring from the students regarding their observations, thoughts, and perceptions relating to patient care. It has been shown by studies that the history contributes to deriving 56% of the diagnosis [4] and a comprehensive physical examination can provide 70%.

Fig. 39.1
figure 1

Example of spiral learning

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Some of the strategies used to ensure adequate teaching through ward rounds and bedside clinics are as follows [5]:

  • Generating interesting questions: The concept of guiding superficial to conceptual learning occurs when the student/resident is fired with questions by the house staff/consultant on the rounds, which would essentially make the latter think ‘out of the box’. This would mean establishing a connection between the theoretical facts with its twists in medical practice.

    For example:

    • Why does blood appear black on ultrasonography? (Ans: Because it does not generate an echo).

  • Making ‘connections’: Establishing connections between medical phenomena and general day-to-day practical learning ensures remembering facts for a long time without having to cram them. The onus lies with the mentor (consultant), who can explain to the students complex techniques and physiological phenomena in a simplified manner by drawing parallels from day-to-day life.

    Examples:

    • Explaining the decrease in intravascular volume associated with hypotension: Comparing the same with leaking plumbing pipes in a household that lead to a decrease in the water pressure and flow.

    • Teaching the effect of a change in bed position on central venous pressure (CVP): Taking the example of a see-saw → when one end goes down, the other end goes up → in other words, when the bed is low, CVP is falsely high and vice versa.

  • Demonstrating contrasting features on rounds : This is most useful when teaching important clinical signs.

    Examples:

    • Auscultation of heart sounds: Differentiating the heart sounds based on the characteristics is better grasped when demonstrated on the patient than learning the same by memorizing from the book. This is a more than 200-year-old technique described in the medical literature [6].

    • Demonstrating the amount of free fluid in peritoneal cavity → by demonstrating the fluid thrill (a large amount of fluid), shifting dullness (moderate), and puddle sign (minimum fluid).

  • Questioning based on hierarchy : Asking a question to the team composed of the undergraduate students, interns, house staff, registrars, and the consultant. The aim is to circulate the question in the team from the junior to the senior most in the round, to generate the most refined answer.

    Example: What is Courvoisier’s law? (The most acceptable response would be the law stated ‘verbatim’: In a jaundiced patient if the gall bladder is palpable, it is seldom due to stone disease vs If the gall bladder is palpable with jaundice, stone disease is unlikely vs Jaundice with a palpable gall bladder is not due to stone disease).

  • Grooming up strategies : Bedside teaching, besides being a platform also plays an important role in the grooming of the young house staff. Paying attention to detail, learning the value of punctuality, enhancing communication skills with the patients, and above all being humble and grounded are some of the other attributes learned through regular bedside rounds. This builds up the skills such as interpersonal communication, rapport building, and gaining a patient’s confidence; attributes that cannot be learned through textbook reading.

figure a

2 What Are the Various Models of Bedside Teaching?

  • The three-domain model of the best bedside teaching practices :

    Suggested by Janicik and Fletcher in 2003 [7], the model emphasizes.

    • Attending to patient comfort: patiently listening to the complaints, counselling about the disease in detail; avoiding technical language, and providing an encouraging disclosure.

    • Focused teaching: diagnose the patient, diagnose the learner, target the teaching, and provide constructive feedback, in private.

    • Group dynamics: aims to keep the group active and attentive during the entire session.

  • Patient-based models :

    Doshi and Brown in 2005 [8], suggested the following patient-based models for effective bedside teaching:

    • Role modelling: Trainee shadowing a senior clinician and learning by emulating the techniques and nuances of the former.

    • Patient-centred model: Allocating patients/beds to a set of trainees, who would be responsible for monitoring their progress from the beginning to the end of their hospital stay.

    • Reporting-back model: Reporting the observations and progress of the patients by the trainee to the mentor.

    • Direct observation: Observation and assessment of the trainee’s progress by the mentor directly on a day-to-day basis.

    • Case conference: Presenting a case by the trainee to a wider audience of mentors.

  • Five-Step microskills model :

    Proposed by Neher et al. in 1992 [9], this five-step model composed of simple, discrete teaching microskills for effective bedside teaching:

    Asking for commitment, probing for an underlying reason, teaching of general rules, reinforcing what has been done, and working on the mistakes. These five elements constitute the five steps of the microskills model.

  • Trialogue—A model of interaction between three groups of players :

    The three groups of players are composed of teachers (clinicians), learners, and patients [10]. The trialogue model focuses on the interaction between these three groups with varying principles, background, and expectations. This enables the clinical teachers to ensure the active engagement of the trainees/learners in the clinical decision-making at the bedside, while simultaneously catering to the needs of the patients and addressing their concerns at the same time.

3 What Are the Types of Bedside Teaching?

Smith et al. proposed two methods of bedside teaching and compared the same with a control group, when examining the cardiovascular system: Demonstration and Practice (DP) and collaborative discovery (CD) [11].

  • DP group: One or a few of the trainees demonstrate the clinical sign in front of the group of trainees and mentors. The mentor would then correct the same and refine it further to show the correct technique to the group.

  • CD group: All the trainees perform demonstration of a clinical skill and report their findings to the mentor. The latter would analyze the same neutrally and point out the errors and the lacunae to the group and would eventually arrive at a consensus to standardize the examination technique. Subsequent to this, the trainees would perform the examination again.

Both the techniques of bedside teaching have been shown to be equally effective in imparting the knowledge of the clinical examination to the trainees. However, Smith et al. had evaluated the skills using an OSCE (Objective Structured Clinical Examination). There was an increase in the learned skills observed in both the groups: 12% for the DP and 10% for the CD. However, compared to the control group, the CD group demonstrated a 5% increase in the finding of key clinical aspects [11].

4 What Is the Current Status of Bedside Teaching in Developing Countries?

According to the reports by Peters et al., the practice of an ideal bedside teaching has decreased from 75% of all the clinical training in 1960s to 8–9% in the current era [12]. According to the amendments by the Medical Council of India in 2017, the graduate medical education curriculum should focus on training students towards taking the responsibilities of physicians of first contact [13]. The theory lectures alone would be incomplete if not complemented with regular bedside teaching and ward rounds with case presentations. In India, the Indian medical graduates get their first-hand experience of dealing with patients during their compulsory one-year internship after completion of their MBBS. During that period, they get the experience of taking decisions in the emergency as well as outpatient department under the supervision of the house staff and the registrars. However, the teaching curriculum during the final two years of MBBS (clinical subjects) focuses on priming the students to get a practical experience of interacting with the patients and formulating the clinical diagnosis and approach to further management. Bedside teaching focuses primarily on the skills of a good history taking, arriving at a differential diagnosis, correlating the theoretical knowledge of paraclinical subjects at devising an approach towards the patient management, exposure to bedside procedures (intravenous cannulation, blood transfusion, insertion of a nasogastric tube, Foley’s catheterisation etc.) and assimilating all the above knowledge to approach a clinical case as an independent physician.

However, there are certain hindrances to conducting proper bedside teaching as well. The most important reasons cited for the gradual decline in bedside teaching worldwide are time constraints due to the pressure to see more patients with increased record keeping and also the worry about patient comfort and privacy during the sessions of teaching [14]. In India, the hospitals are mostly divided into the public sector (government funded) and private sector. The former includes the medical colleges and the latter include the teaching hospitals (mostly involved in postgraduate medical education only). The biggest hindrance towards bedside teaching in the public sector has been the lack of accountability of the senior faculty members towards conducting ward rounds, leaving the same mostly at the discretion of the house staff and the registrars (who are usually overworked). The hindrances in the private sector hospitals have been a lack of incentive for the faculty to conduct regular bedside teaching (where most faculty have their busy OPD schedules and are not paid for their academic roles) and also the concern regarding the patient comfort and privacy during the bedside teaching sessions. Factors such as the greater reliance on technology such as sophisticated radiological investigations to arrive at a diagnosis without spending much time on arriving at a diagnosis based on clinical findings have been also contributory towards the decline in the trend of regular bedside teaching. For example, when asked about identifying the possibility of right-sided pleural effusion in a patient with dyspnoea, the ‘knee jerk’ response by the trainee would be to order a Chest X-ray or Ultrasound examination, instead of considering bedside percussion or auscultation. With increase in the technological armamentarium of the clinician, there is a decline in the importance of basic bedside clinical tests that would help arrive at a diagnosis. Even for diseases like acute appendicitis, where 98% of the diagnosis relies on bedside clinical findings, the first-line approach is to order for an ultrasonography of the right iliac fossa or a CT scan of the abdomen (especially in private sector hospitals). Another important factor that has come into play in 2020 is the COVID-19 pandemic that has led to a widespread disruption of the regular teaching curriculum in all medical institutions and hospitals. With lockdown of the teaching institutions being imposed to minimize social contact, there has been a major shift in the modes of undergraduate teaching. Newer platforms such as e-learning through Zoom, and Microsoft meetings are being used to conduct lectures. Virtual case scenarios are being discussed with clinical signs being demonstrated on dummies on a cyber platform. Even examination patterns have shifted from bedside discussion of cases and evaluation to OSCE (mainly being conducted through the display of virtual cases on a computer screen) and clinical case simulations. Even though, these have been the only possible measures that could be taken to ensure an uninterrupted flow of classes, the importance of learning the nuances of bedside clinical signs cannot be undermined in any medical teaching curriculum.

In a study by Holla et al., the following factors were identified by the medical and surgical faculty as the hindrances to a smooth bedside teaching [15]:

  • Bigger group sizes in smaller arenas.

  • Increased workload of the faculty (administrative/research) and house staff (high patient load).

  • Language barrier for the students (especially in India, with different languages in different states).

  • Shorter length of patient stays in hospitals.

  • Lack of patient cooperation.

  • Interruptions due to phone calls, visitors, noise in the wards.

  • Lack of an incentive for the faculty to take dedicated bedside classes.

  • Miscellaneous (students not following decorum, lack of infrastructure in the ward such as viewing boxes).

5 What Are the Ways Forward?

Some of the ways suggested to overcome the decline of bedside teaching are as follows:

  • Compulsory allocation of time for bedside teaching with detailed planning :

    The clinical postings composed of nearly 2–3 hours of the curriculum in undergraduate teaching during the pre-final and the final professional years in India. However, effective bedside teaching usually gets limited to only half an hour to 45 minutes. This could be improved by prior allocation of a faculty or registrar to this duty for a particular day, well in advance, so that one particular faculty member is responsible for conducting the teaching. The teaching method should be patient-centric instead of a theoretical discussion in the demonstration room. The expectations by the faculty should be kept realistic and a gradual step-by-step escalation of skills by the students should be aimed at.

  • Ensure patient comfort :

    Even though it has been speculated and observed by many that bedside teaching might cause discomfort to most patients, a study by Nair et al. reported that contrary to this belief, most patients report to be benefitted from bedside teaching by understanding their own problems [16]. Having said that, basic etiquette by the clinician cannot be undermined. Emphasizing the importance of taking consent from the patient prior to the examination, introducing himself to the patient prior to initiating the encounter, lateral conversation (without breaching professionalism) for good rapport building, keeping medico-legal pre-requisites in mind (especially when examining a female patient or doing a genito-urinary/breast/rectal examination) are some of the important points that need to be re-emphasized during every session of bedside teaching.

  • Focused approach by the teacher and the student :

    Bedside discussions of cases are highly prone to tangential detours. This usually stems from over inquisitiveness of the student (who feels the urge to know everything in one day) or an irrational approach by the mentor (who derives a pleasure asking ‘out of the context’ questions to the student). The remedy to this problem is by strategizing the goal of the class in advance. A checklist of the ‘must-to-do’ signs/manoeuvres/techniques should be formulated, and the teacher should make sure that these have been achieved by the students at the end of the class. An ideal bedside teaching should make the students learned and more conceptual in their clinical approach and not leave them confused with garbled facts and figures difficult to comprehend and recall.

  • Integration of case-based learning (CBL) :

    A study by Kulkarni et al. in 2019 reported highly positive results by integration of case-based learning strategies to bedside clinics [17]. Their study reported a high level of motivation among the students by this approach (88%). Authors such as Dubey et al. and Nair et al. reported similar results by showing 74–98% motivation among the students to learn using additional resources by this approach [18, 19]. An interesting way to make bedside teaching more interesting is framing case scenarios and allowing the students to solve them similarly in the way they would as clinicians sitting in the out-patient department. This approach is similar to the pattern followed by the United States Medical Licensing Exam (USMLE) in their final step 3 (Clinical Case Simulators). For example:

    Case: A 50-year-old lady comes to the Emergency Room with fever and severe pain in her right hypochondrium.

    Approach:

    Step 1: Overall assessment of the patient → vital signs, state of hydration.

    Step 2: Focused clinical examination → eliciting Murphy’s sign; Rebound tenderness

    Step 3: Next line investigation → Total leucocyte count, Ultrasonography of the abdomen

    Step 4: Prepare the patient for lap/open cholecystectomy based on the fitness and other laboratory parameters

6 Conclusion

  • Bedside clinical teaching is an open arena to translate theoretical learning into a practical application for budding clinicians.

  • The importance of the clinical approach by taking a meticulous history and attention to detail in assessing the physical signs cannot be undermined in the light of the recent greater dependence on the ancillary tools of investigation such as CT scans, MRI.

  • Bedside teaching will provide a strong foundation pillar to a future clinician and should therefore be an indispensable component of every undergraduate and postgraduate medical curriculum.