A Comparison of Bedside Teaching: Real Patient, Simulated Patient and Manikin
Nurudeen S. Bello; Janice A. Cherniwchan; Salma R. Imran; and Chantal B. Lecuyer
Experiential Learning: The Theory Behind Bedside Teaching
“Educational learning is described as a process whereby concepts are derived from and continuously modified by experience”. (kolb, 1984). David Kolb defines experiential learning as “the process whereby knowledge is created through the grasping and transformation of experience” (Kolb, 1984). The experiential learning involves four cyclical stages: concrete experience, abstract conceptualization, reflective observation and active experimentation. (Kolb, 1984).The concrete experience is a new experience or situation encountered and depends upon the learners willingness to learn.(Kolb, 1984). It is then followed by a reflective observation where the learner evaluates his learning and improves the areas needed (Kolb, 1984). Abstract conceptualization is when the learner forms new ideas and concepts or modifies existing ideas after having reflected on the experience (Kolb, 1984). Last of all, the active experimentation stage is where the learner applies the new ideas to a similar situation to see if there are any changes to the outcome.(kolb, 1984).
According to Kolb, “concrete experience provides information that serves as a basis for reflection,from these reflections, we assimilate the information and form abstract concepts” (Kolb, 1984.) People then practice these concepts to cultivate new theories, which they then experiment in their real life (Kolb, 1984). By experimenting our ideas and skills that we have acquired, we once again gather new information that we bring together from our experience and drive it back to the initiating process (Akella, 2010). To acquire new knowledge, a learner can start from any stage of Kolb’s cycle of experiential learning but in order to improve the learning outcome, one has to complete all the stages and follow them in sequence (Akella, 2010).
“Bedside teaching is a specialized form of small group teaching that takes place in the presence of the patient.” (Rahman, 2017). There are many techniques and skills that cannot be taught in a classroom and require the presence of a patient. (Qureshi, Maxwell, 2011). Hospital is the ideal environment where bedside teaching (BST) and learning skills are used as it allows exposure with the real patients.(Amer et al., 2006). Apart from learning through real-life patients in hospitals, it can also be experienced by using simulated patients (SPs). (Bokken et al., 2008). Learning at the bedside of a patient is the best way to learn examination techniques and exposes the learner to the relevant knowledge about different medical conditions with its differential diagnosis, thereby improving the learning experience and patient care ( Bokken et al., 2008;see also Rahman, 2017 & Amer et al., 2006). BST and learning in the hospital wards takes place in a small group in the company of a patient and an instructor (Ray & Ganguli, 2009;see also Rahman,2017). The smaller number of people allows the members of the group to actively participate in the discussion and demonstrate the clinical examination without causing distress to the patient and the medical staff (Ray & Ganguli, 2009).
Simulation is an alternative to an actual patient and is widely used as a BST approach to teach history taking, and examination techniques (Bokken et al., 2008). Working with SPs or manikins builds good judgement and a sense of confidence among the students since practicing with either can be repeated, which adds the chances to correct the inaccuracies (Bokken et al., 2008). Although it is as effective as real patient experience, it is not considered the ideal method to deliver the knowledge as it does not mirror the actual clinical exposure (Qureshi & Maxwell, 2012). Skills like obtaining a patient’s relevant history and performing appropriate physical examination in order to arrive at a clinical diagnosis are best achieved with a real patient. (Bokken et al., 2008). As discussed, the BST is where experiential learning can be applied, it can be performed in a variety of environments.
Learning Environments and Tales from the Field
When considering BST, the most common environment that comes to mind, is the hospital. Of equal importance, is determining when it should be introduced. It is recommended that it be used for undergraduate medical education (Qureshi & Maxwell, 2011; Krishnan, Keloth, & Ubedulla, 2017). What should be considered when doing BST in the hospital setting? Are there alternative environments that should be considered? The next few paragraphs will answer these questions.
Undergraduate students recognize the value in using BST as a teaching tool as it offers patient-centered learning (Bokken, Rethans, Scherpbier, & Vleuten, 2008; see also Qureshi & Maxwell, 2011). However, patient availability is unpredictable, learner experience is variable, and patient comfort and confidentiality must be considered (Bokken, et al., 2008; Qureshi & Maxwell, 2011). To influence the later two, Carlos et al. (2016) suggest the following four factors be considered: climate, attention, reasoning and evaluation. These are further described below:
- Climate. Advanced planning will ensure that learners and patients are comfortable with the teaching opportunity (Carlos et al., 2016). Expectations must be communicated with both the learners and patients. Remind learners to minimize the use of medical jargon and to clarify with the patient their preference about having family or visitors present (Carlos et al., 2016). The patient and those present must also give consent to participate in the teaching experience and be encouraged to ask questions (Carlos et al., 2016). It is also important to let the patient know that side conversations may occur that may not pertain to them (Carlos et al., 2016).
- Attention. To help maintain the focus, try to minimize any distractions, such as using your cell phone or having the television on in the room (Carlos et al., 2016). It is also best to pre-determine the amount of time allotted for the interaction (Carlos et al.,2016). Keep the encounter concise, and ensure to engage all learners by asking questions that require all to participate (Carlos et al., 2016).
- Reasoning. Let learners process the information, formulate interventions, and apply reasoning skills (Carlos et al., 2016). Ensure to use probing questions or questions on behalf of the patient and encourage them to think out loud (Carlos et al., 2016).
- Evaluation. Provide learners with formative feedback to help modify behaviour for the next similar encounter (Carlos et al., 2016). Any critical feedback should be kept in mind and discussed once the interaction is over so as not to embarrass anyone (Carlos et al., 2016). At times delayed feedback may be appropriate as this allows learners the opportunity to reflect on their encounter (Williams et al., 2016). Further delaying the feedback will create an opportunity for the learner to communicate with other members of the team, and as a result can enhance the feedback session (Carlos et al., 2016).
If well thought out, BST within the hospital can be positive for all those involved (Qureshi & Maxwell, 2011). The Emergency Department is one of the hospital’s ideal locations for BST (Amer et al., 2006). This is largely due to its high volume of patients, variability in pathologies and procedural skills opportunities (Amer et al. 2006). It is also a challenging environment to provide teaching because overcrowding is not uncommon and time is understandably limited (Amer et al. 2006; Qureshi & Maxwell, 2011). This in turn can have a negative impact on the quantity and quality of BST opportunities resulting in learning gaps (Qureshi & Maxwell, 2011). However, the opportunity to interact with an individual with true abnormal findings is invaluable (Bokken, et al., 2008). Unfortunately, these interactions are unique and exposures cannot be replicated or standardized (Qureshi & Maxwell, 2011). This, we imagine, may be a curriculum concern for undergraduate programs, as not all learners will graduate with the same experiences (Bokken, et al., 2008). As a result, it makes us question whether the hospital setting and their patients are ideal for such learning? What other opportunities can we provide learners to ensure a more standardized curriculum?
An alternative to working with real patients, is the use of SPs. These are individuals recruited and trained to simulate a real patient and provide standardized learner encounters (Bokken, et al., 2008; Lioce et al., 2020). Ideally, SPs should be well trained so that they are indistinguishable from a real patient, which preserves authenticity and assumingly enhances learning (Lioce, et al., 2020). Standardization is made possible because “they are available when needed, adaptable to students’ needs, offer uniformity of educational experiences across students, and enable repeated practice of skills” (Bokken, et al., 2008; Krishnan, Keloth, & Ubedulla, 2017). Since SPs are paid for their time, an approach to consider may be utilizing real patients whenever feasible and SPs to fill in the education gaps. Alternatively, they can work with SPs until they have mastered basic skills and then move on to work with real patients (Bokken, 2008). Additionally, certain real patients, such as those with specific medical conditions, can be recruited in a SP pool to provide learners with standardized exposures. This is commonly done at the University of Saskatchewan Clinical Learning Resource Centre (CLRC) for the School of Rehabilitation Science program.
An alternative to typical BST, is in-situ simulation. This has been used at the CLRC in coordination with certain departments at Royal University Hospital (RUH), albeit not for BST. It is typically used in a group setting to improve communication skills and to identify system, environmental and team gaps (Patterson, Blike, & Nadkarni, 2008). Things to consider in this environment will be space availability, just as we explored above, space is often limited within the hospital (So, 2019). RUH’s in-situ sessions have often been canceled due to a lack of space and this was noted at Cincinnati Children’s Hospital Medical Center (CCHMC) as well (Patterson, Blike, & Nadkarni, 2008). In an effort to minimize cancelations, CCHMC sets specific time limitations for their scenarios (10 minutes) and debriefing sessions (7 minutes), while following up with a participant survey (Patterson, Blike, & Nadkarni, 2008). Although, if used for BST more time would need to be allotted as “it often takes time to sensitively, and accurately get a thorough history from a patient. The balance of being efficient with time, yet establishing a rapport with patients can be learned” (Qureshi & Maxwell, 2011).
Alternatively, environments outside of the hospital setting should be considered for a more sustainable option. There has been a decline in BST, for a number of reasons which supports the idea that other methods should be explored, such as simulation (Amer et al., 2006; Qureshi & Maxwell, 2011). It also consists of the four factors that Carlos et al. (2016) identified; climate, attention, reasoning and evaluation.
- Climate. Both the learner and manikin or SP will be suitable for the learning experience since the interaction will occur in a controlled setting. Expectations can be outlined with learners and SPs if present. During simulation sessions, expectations are outlined in the pre-debrief, which is the first of three phases of a simulated scenario (Lioce et al., 2020).
- Attention. Simulated scenarios, which is the second phase of the session, encourages all learners to actively engage (Lioce et al., 2020). There are also minimal distractions to be concerned about, unlike the busy hospital setting (Qureshi & Maxwell, 2011).
- Reasoning. The simulated setting allows learners to process, evaluate and when appropriate be interrupted to discuss content (Bokken et al., 2008; Lioce et al., 2020). The simulator’s response and SP encounter can be adjusted based on the learners level to improve the learning experience (Bokken et al., 2008). At the CLRC and likely other simulation centres, probing questions are asked by the manikin, via the Simulation Operator or trained SP to encourage reasoning.
- Evaluation. All simulated experiences should be followed by a debrief, which is the third phase of a simulated session, at which point learners receive feedback (Lioce et al., 2020). Although, Carlos W.G., et al. (2016) discusses a delayed debriefing for certain situations, that would not be appropriate here as learners should always debrief immediately after their scenario as that is part of the learning activity (Lioce et al., 2020). Debriefing is the faculty’s opportunity to provide feedback and encourage learner reflection (Lioce et al., 2020). Additionally, in some situations, SPs are also trained to provide feedback (Bokken et al., 2008).
It is very likely that the most effective alternative to BST is simulation, as learners are able to develop the necessary skills (Qureshi & Maxwell, 2011; So et al. 2019). Faculty have commented that they appreciate simulation for its ability to expose learners to uncommon situations or those that learners have not had an opportunity to see within the hospital setting (Patow, 2005). Additionally, faculty have mentioned that simulation allows them to expose learners to common situations or apply concepts recently learned in lecture. Simulated environments, such as the CLRC, use manikin based simulation, task trainers (models that resemble part of a human body) and SPs. Our SP pool consists of individuals that enjoy participating in educational experiences and have flexibility in their availability. They include, but are not limited to, individuals trained to portray a certain patient or those with specific disabilities. We will also simultaneously utilize a task trainer with an SP or manikin, such as a wearable breast model attached to a SP or a chest tube insertion model next to a manikin. We are able to provide learners with requested diagnostic results, such as bloodwork, radiographs, and ultrasound videos all within an environment that reflects the hospital setting, right down to the equipment. This in turn permits us to offer a wide variety of student-centered experiences and provide both healthy and abnormal interactions that are standardized.
The different environments in which BST can be utilized, whether hospital or simulated-based, with the use of real patients, SPs or manikins are not without limitations and the section to follow will further delve into this.
Medical education has traditionally relied on training with real patients in actual clinical settings. While experiential learning is indispensable, medical educators are increasingly concerned about, and committed to the safety of patients (Patow, 2005). In the writer’s clinical experience, clinical BST began in clinical postings, where medical students interacted with real patients. Mistakes, if made, were done in the presence of well-trained clinicians who in turn correct the mistakes as part of the learning process (Patow, 2005). The role of real patients cannot be overemphasized in clinical practice (Patow, 2005).
With simulation learning, medical students, especially those in preclinical classes, have the opportunity to develop their skills using simulation technology (Patow, 2005). Simulation is not limited to medical students alone, nursing students, as well as residents of various specialties employ the learning strategy (Patow, 2005). The next section of this paper will address the strengths, weaknesses, opportunities, and threats, termed SWOT analysis, of BST strategies with real patients, SPs, and manikins.
SWOT Analysis of Bedside Teaching with Real Patients
Strengths. BST with real patients has historically been a way of instruction for medical students. It is viewed as “an effective way to develop physical examination, history taking, and communication skills” (Bokken et al., 2008). Further discussed by Bokken et al. (2008) medical students found value in watching clinicians’ demonstrating skills during BST. Exposure to real patients provides a human connection which changes “the student experiences not just how to assess disease, but beyond this, how to personally and professionally address the human impact of illness” (Qureshi & Maxwell, 2011). Assessment on real patients “provide value to the student and the clinician by supplying indispensable information regarding their signs and symptoms” (Narayanan & Nair, 2020). Communication skills develop as medical students work side by side along with experienced practitioners and build their levels of experience with the doctor patient relations (Qureshi & Maxwell, 2011). Lastly, teaching at the bedside, allows both medical students and their patients the opportunity to deepen their knowledge based on their disease process. (Narayanan & Nair, 2020).
Weaknesses. In more recent years, BST of real patients has significantly declined (Qureshi & Maxwell, 2011). The reason for this decline appears to be multifactorial. One impacting belief was related to “differences between individual clinical teachers and the uncertain availability of suitable patients” (Bokken et al., 2008). The reduction of available patients is a result of shorter and more complex hospital stays (Qureshi & Maxwell, 2011). This detrimental decline of available patients further impacts the amount of patient contact the medical professionals will experience (Bokken et al., 2008). Other barriers reported were the complexity of the patient’s medical condition hindering their participation in BST (Bokken et al., 2008). Despite a willingness to teach, the clinician faces increasing demands of rising patient consultation and documentation, leaving no additional time to invest in BST (Qureshi & Maxwell, 2011). Qureshi & Maxwell (2011) further note that BST has been viewed as “intruding or demeaning to patients”. Due to advancements in medicine, “a wide availability of diagnostic testing, together with a culture that too often incentivizes getting a scan, has led to a reduction of time spent on the physician’s clinical examination of the patient” (Rutledge & Simpson, 2018).
Opportunities. Simulation offers students a safe, controlled setting in which to experience the initial stress, awkwardness, and confusion associated with clinic visits (Wisenberg, 2017). In the writer’s clinical training, medical students have the opportunity to be the first to come in contact with new patients, hear their complaints, reach a diagnosis before presenting to licensed healthcare professionals, who then evaluate the patient and provide appropriate interventions in the management of the patients. This way, medical trainees get appropriate feedback from both their trainers, and the patients. This can provide the opportunity to assess trainees’ clinical competence, interpersonal skills, as well as empathy (Wisenberg, 2017).
Threats. According to the competencies from the Accreditation Council for Graduate Medical Education (1999), provision of compassionate and appropriate patient care is one of the expectations of good medical practice. Thus patient’s safety is of great importance. One of the threats associated with learning with real patients is that patients with serious and volatile conditions may not get a second chance if safety is compromised (Wisenberg, 2017).
SWOT Analysis of Bedside teaching with Simulation Manikins
Strengths. New emerging technology in medical education is the use of simulation-based BST. The technological advancements have grown exponentially and bear many strengths, which will be discussed in this section. Krishman et al. (2017) noted the application of knowledge and hands-on skill development are advantages of simulation-based BST. The opportunity to first experience an event in a simulated environment allows for more significant learning for the student (So et al., 2019). Self-confidence develops when students are allowed to partake in simulation learning before applying skill to real patients (Krishman et al., 2017). The use of simulation training will also “standardize[d] examination for clinical competence” (Krishman et al., 2017). A significant advantage of simulation is creating a safe environment where skills can develop free from potential harm, allowing multiple attempts to develop skill sets (Krishnan et al., 2017). Simulation BST allows the opportunity “for learners to experience failure, and to recognise when they are approaching or crossing the limits of their competence” (So et al., 2019).
Weaknesses. Narayanan & Nair (2020) describe the impact of “negative learning” from simulation as it relates and exemplifies the inability to exactly depict signs and symptoms in clinical scenarios. A simulator can never truly replicate the complexities of the human body.(Krishnan et al., 2017) The development of the student’s conversation skills is negatively impacted by artificial interaction with SPs (Narayanan & Nair, 2020; So, 2019).
Opportunities. Exploration using simulation ensures core knowledge relevant to medical students, or learners in general. Simulation based learning advances medical learning and ensures that learners learn procedures and treatment protocols before eliciting them on real patients (Patow, 2005). This in general helps learners develop skills without putting patients’ at risk (Patow, 2005). Simulation provides learners with the opportunity to deliberate practice, as such they make mistakes in a safe environment, learn from those mistakes and achieve proficiency by attaining predefined benchmarks (Aggarwal et al., 2006). According to Ankel and Hegarty (2004), it is clear that most healthcare trainees, especially residents, experience the tension and feel the pressure of dealing with seriously ill patients in crisis situations in the simulation scenarios. They appreciate the chance to stimulate cases that they may not see in their emergency room shifts (Ankel & Hegarty, 2004). Simulation is efficiently used to promote team training, due to its interactive and practical nature (Salas et al., 2008). The key principles of team training in healthcare can be embodied in using simulation as a learning tool (Salas et al., 2008).
Threats. A key to the success of simulation training is integrating it into traditional education programs (Patow, 2005).Training in simulation is a step between classroom instruction and actual clinical instruction with real patients (Patow, 2005). For some faculties, it can be difficult to translate lecture materials to a hands-on simulation environment (Patow, 2005). Although high-fidelity simulators may be expensive, some simulation training may be effectively undertaken with lower fidelity manikins, reduced equipment costs and constraint (Kim et al., 2016). In some situations, incorporating simulation-based education in an already burdened system is difficult, as both trainers and learners need to be released from clinical duties to attend training courses with healthcare and hospital cost implications (So et al., 2019). Changing speed of technology, and medicine can stand as threats in development as well as improvement of simulation training. Simulation may be obsolete in a couple of years, some simulation equipment will be upgraded under manufacturers’ warranty, but some will not (Patow, 2005). There is also a need to develop a pool of qualified trainers, while at the same time maintaining standardization (So et al., 2019). Many trainers in healthcare education are full time healthcare professionals, and part time trainers, and may not have the time to teach frequently, and therefore could potentially lose their debriefing skills (So et al., 2019).
BST is viewed as a valuable teaching tool and is best introduced early on in the training of medical professionals. As this chapter identified, it can be applied in a variety of settings such as the hospital and a simulated environment with the use of real patients, SPs or manikins. After conducting a SWOT analysis, we were able to identify the strengths, weaknesses, opportunities and threats of each of these settings. The consensus is that working with a real patient within a hospital, although valuable, because it cannot be fully replicated that simulation be considered as an additional modality. Simulation should not be an alternative to traditional BST, but rather an addition. (Krishnan, Keloth, & Ubedulla, 2017; So, 2019) Simulation may be considered the superior modality for certain skills but does a good simulation performance translate to clinical practice? (Krishnan, Keloth, & Ubedulla, 2017) According to Krishnan, Keloth, and Ubedulla (2017) and So (2019) more research should be done in this area. Furthermore, the creation of partnerships between institutions, such as hospitals, medical colleges and simulation centres may make this more a feasible option (Patow, 2005). This suggested supplemental approach would allow for medical schools and hospitals to overcome the restrictions and limitations associated with the traditional approach (So, 2019).
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