Ask the Experts: Ten Tips for Effective Bedside Training
As a resident in a program of U.S. graduate medical education (GME), you expect to learn a lot. But did you know that U.S. residents are teachers as well as learners?
The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the accreditation of residency education programs in the United States. The ACGME defines professionalism as a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. In U.S. GME, teaching and education are at the core of these professional responsibilities and a requirement among medical students, residents, attending physicians, and patients.
Throughout your career, individuals will look to you for your up-to-date knowledge and timely answers to many important questions. Your teaching efforts will be documented and evaluated by attendings, medical students, residents, and multidisciplinary hospital staff. Residents need to learn to identify key teaching areas in the health care environment and to recognize the best practices for teaching in the classroom as well as, one of the most important places, the patient’s bedside.
We reached out to teaching expert, Vijay Rajput, MBBS, to discuss some of the most important and effective teaching methods to use at the bedside. Throughout his career in medicine, he has seen patient care change and as a result has had to adapt his teaching styles. With more than 15 teaching awards from medical students, residents, and colleagues at his own institution and as the recipient of several national teaching acknowledgments, Dr. Rajput has proven that his methods are effective in teaching medical students, residents, colleagues, and patients at the bedside. He notes that residents are required to learn how to be familiar with the preparation of the patient and team for bedside teaching; to identify common rules and guidelines for team-based teaching at the bedside; to recognize and practice bedside evidence-based physical diagnosis; and to learn to actively involve the patient in bedside teaching. The following ten guidelines suggested by Dr. Rajput provide a basic framework to help you better understand some of the many bedside techniques needed in the U.S. health care system to promote the best learning and patient-care settings.
- Prepare the team before entering the patient’s room.
Before entering a patient’s room, every member of the team should know the teaching styles and expectations of the attending and teaching residents. The information presented to the team may include the goals for interacting with the patient, how to maintain professional conduct, and how to convey important aspects of patient care at the bedside.
- Prepare the patient.
The entire team should be introduced to the patient. Proper introductions should include full names and level of learning (attending, senior resident, junior resident, medical student, etc). The patient’s permission related to the teaching process of their medical problem should be obtained, and the patient should be thanked for helping educate the team. The patient should also understand that he/she can participate in and correct any information presented during the conversation at any time. With the patient’s permission, family members may stay in the room and get involved in the teaching rounds, if they need some clarification on patient care issues.
- Listen and respond to the patient and the family.
The patient should be asked about any concerns or questions he/she may have about the condition and treatment, and it is important to listen to this information. These questions and concerns can be a good starting point for teaching, as these often raise important issues that need to be addressed. Asking the patient about concerns also helps the patient get involved in his/her own care. Teaching related to the needs of the patient can expedite patient care and also make this care truly patient-centered. The concerns of the patient may also be different than the concerns documented in the patient’s chart. Notes about what patient needs are for the day should be written in the chart, including how and when those needs will be addressed.
- Think out loud.
When talking about the patient’s condition, the facts should be explained clearly. Any next steps should be stated in simple language that can be understood by the patient and all team members, no matter their level of knowledge. The concerns of the patient should be spoken out loud to all the team members, and their feedback about how to address these should be solicited.
- Find the teaching moments.
Students and residents should observe the patient and perform a physical examination, describing any key observations to the team. The attending and/or senior resident will monitor the students and residents performing the physical examinations to ensure they are doing it accurately and that all key points are being reviewed. To assist with the discussion, drawing pictures of anatomical organs and patient disease at the bedside could be helpful for team learning and could benefit the patient’s understanding. If there is literature about the patient’s condition being discussed, a copy of this should be given to the patient to read at a later time.
- Involve nurses and other health care professionals.
Many individuals are involved in each patient’s care and together all health care team members strive to attain the same goal—provide the best care for the patient. When available, nursing staff and other health care professionals such as a case manager, pharmacist, and physical therapist, should attend the bedside rounds. These professionals may have spent a significant amount of time with the patient and can offer helpful information for patient care and for the education of the team.
- Feel comfortable saying “I don’t know.”
Learning and being comfortable saying “I don’t know” in front of the team and the patient is very important to the integrity of the bedside teaching experience. Patients will respect your saying “I don’t know” as long as you can back that statement up with how you are going to find out what it is you don’t know.
- Let the patient share a personal story.
Some physicians like for patients to share some prior life and work experience with the team members. If the patient wants to do so, this helps him/her feel more comfortable and connected to the team. It can also provide a more meaningful experience for everyone. It is important to bring this humanistic aspect to the rounds and make the team feel more connected with the patient.
- Explain the next steps involved in the patient’s treatment.
Follow up items such as test results, speaking with the nurse, and other next steps involved in a patient’s treatment plan should be clearly addressed and talked about before leaving the room. This information should not be rushed in order for the team to get to the next patient, but should be detailed clearly so the patient knows what to expect.
- Don’t limit teaching to the bedside.
Avoid teaching everything about the patient’s care and disease at bedside. There will be other times to teach, such as in the classroom and in a conference room, both of which may be more appropriate times to talk about certain topics, especially at length.
About the Expert
Dr. Vijay Rajput, MBBS, FACP, SFHM
Dr. Vijay Rajput, MBBS, FACP, SFHM, is Professor of Medicine and Assistant Dean for Curriculum at Cooper Medical School of Rowan University in Camden, New Jersey. He also serves as the Head for Division of Medical Education in the Department of Medicine. Prior to that from 2004-2012, he served as Program Director of the Internal Medicine residency program at Cooper University Hospital, UMDNJ/Robert Wood Johnson Medical School in Camden, New Jersey.
Dr. Rajput has authored or co-authored more than 60 papers, abstracts, and book chapters. He has presented more than 150 seminars, workshops, and grand rounds at national, international and regional educational conferences. Since 2010, he has served as a Guest Editor for the Ethics Section of the “Yearbook of Critical Care Medicine.” In 2009, in collaboration with the American College of Physicians (ACP) and ECFMG, he co-edited a book entitled “The International Medical Graduate’s Guide to US Medicine & Residency Training.”
Over the last 15 years, Dr. Rajput has received more than 15 “Excellence in Teaching” awards from students and residents. He was recently awarded the ACGME Parker J. Palmer “Courage to Teach Award”—the most prestigious teaching award—in its 10th year. He also received the prestigious Christian R. and Mary F. Lindback Foundation award for Distinguished Teaching in 2006 and was inducted in the UMDNJ’s Master Educator Guild in 2005. In 2004, Dr. Rajput received an “Excellence in Teaching Award” from the Society of Hospital Medicine.
His main areas of interest are bedside teaching, real-time Evidence-Based Medicine, professionalism, ethics and humanism in medicine, as well as problem-based learning and curriculum development. He lives in the Philadelphia suburbs with his wife and two daughters.