Working as a health care provider is a career held in high regard by society and consequently, the expectations of training programs to produce professional and competent trainees is immense. The privilege of providing health care to individuals and their loved ones, such as through delivery of dental hygiene or veterinary medicine, comes with great expectations and responsibility. “Medical education’s ultimate aim is to supply society with a knowledgeable, skilled and up-to-date cadre of professionals who put patient care above self-interest, and undertake to maintain and develop their expertise over the course of a lifelong career” (Swanwick, 2014). In order to meet these demands, training programs are required to frequently reflect and adapt to ensure teaching remains congruent with the development of proficient health care providers. Furthermore, the constantly evolving use of technology in health care education, such as the introduction and widespread use of high-fidelity simulation, has resulted in drastic changes in the way health care students are taught and evaluated. Despite these changes over the years, many of the fundamental principles of education and learning are still prevalent and form the foundation for curriculum development.
Principle to the development of a robust curriculum for health care providers is the influence of learning theories afforded by the advancing field of learning research (Grant, 2014). Kauffman and Mann (2014) identified the following eight learning theories as having a significant impact in the field of medical education: adult learning principles, social cognitive theory, reflective practice, transformative learning, self-directed learning, experiential learning, situated learning, and learning in communities of practice. Of these eight theories, the role of experiential learning is essential to all health care professions. The theory of experiential learning is born from the work of theorists such as John Dewey, Kurt Lewin, and Jean Piaget. However, one of the most influential theorists in this field was David Kolb, who “defined learning as a ‘process whereby knowledge is created through the transformation of experience’” (Yardley et al, 2012). We will discuss Kolb’s theory in more detail in the following section, Learning Environments. Put another way, “experiential learning methods and procedures are bridges connecting a learner’s existing level of understanding, philosophies, affective characteristics and experiences with a new set of knowledge, abilities, beliefs and values” (Kauffman and Mann, 2014). For over a century, the use of experiential learning has been a pillar in the training of medical students and residents due in large part to the advocacy of Sir William Osler. One such method first accredited to Osler is the practice of bedside teaching (Swanwick, 2014). This chapter will build on the work of Bello et al in “Instructional Strategies in Health Professions Education” by further examining the use of standardized patients in bedside teaching of medical trainees. We will begin with an introduction to what bedside teaching is, what it looks like, and how to apply it to teaching contexts. Next, we will evaluate the steps of beside teaching using real patients and compare to bedside teaching using standardized patients. Lastly, we will perform a SWOT analysis (strengths, weaknesses, opportunities, threats) and provide tales from the field.
Description of Strategy
What is bedside teaching?
Within the medical field, the model of bedside teaching is when a teacher takes learners to a patient’s room to either demonstrate or evaluate components of a history or physical exam relevant to the patient’s presentation to hospital. For many decades, bedside teaching was “seen as a primary teaching modality in which most aspects of clinical practice can be demonstrated and trained” (Peters & Ten Cate, 2014). Interestingly, the use of bedside teaching not only a preferred teaching modality for students and teachers, but patients also report greater satisfaction with their care when they partake in bedside teaching (Peters & Ten Cate, 2014). Other benefits of bedside teaching include the direct observation of “patient-centered care”, participation in the doctor-patient relationship, and exposure to genuine disease pathology that may not be amenable to replication in simulation (Qureshi, 2014). Although not many studies have been performed evaluating the objective evidence for bedside teaching, a study by Cooper et al (1983) did show promising results. Students were shown a video of how to perform a comprehensive physical exam of the abdomen and then participated in a morning practice examination. In the afternoon, the students were split into two groups. The “control” group received a session on history taking while the “experimental” group had bedside teaching of the abdominal exam. One week later the students were evaluated on their performance of the abdominal exam, with students in the “experiment” group performing significantly better than the “control” group.
What does bedside teaching look like?
While bedside teaching can occur in many different contexts and settings, there are fundamental components that must be present for bedside learning to be successful. According to Garout et al (2016), bedside teaching must occur in a clinical environment and all three parts of the learning triad (patients, students, and tutors) must be present. Garout et al (2016) explain further:
“Each individual member brings his or her own value to the learning triad. For example, the student brings medical knowledge and the eagerness to learn; the tutor brings depth of knowledge, mentorship, and willingness to help the student learn and make connections; and finally, the patient brings the relevant clinical issues to the forefront that allow the student to learn.”
How to apply bedside teaching to teaching contexts
The relative ease of applying bedside teaching makes it a desirable teaching method as all that is needed is the learning triad and a clinical environment (Garout et al, 2016). Despite this, the use of bedside teaching is declining. During the 1960s, bedside teaching was estimated to represent as much as 75% of all clinical training while estimates from 2014 showed a drastic decrease to only 8-19% (Peters & Ten Cate, 2014). The reasons for this waning in bedside teaching are multifactorial but some of the prominent causes including busier hospitals with faster patient turnover, greater demands on physician’s time on tasks other than teaching, and the increasing reliance on laboratory and diagnostic results to aid diagnosis over the history and physical exam (Peters & Ten Cate, 2016). These pressures have set the stage for the shift from bedside teaching with real patients to the use of simulated patients. A simulated patient is “a lay person who has been trained to portray a patient with a specific condition in a realistic way” (Cleland et al, 2009). Simulated patients have helped revive bedside teaching by the ability to provide students a wide variety of experiences they may not encounter in real patients, assessment reliability, predictable behaviour, and they can be used in scenarios where practicing on a real patient would be in appropriate such as when delivery a terminal diagnosis (Cleland et al, 2009). Furthermore, the ability to plan these sessions ahead of time is a great advantage to students with demanding schedules. Next, we will discuss the learning environments for bedside teaching.
Learning Environments: Bedside teaching or teaching in a simulated scenario
Globally medical students are trained with real case scenarios, as said by Sir William Osler that “medicine is learned by the bedside and not in the classrooms” and still learning this skill is as essential as was in the past (Rutledge & Simpkins 2018). In the context of four learning environments that are described by (Kolb 1979); feeling (affective orientation), cognitive (symbolic orientation), observation (perceptual orientation) and performance (behavioral orientation) (Kauffman & Mann 2014) bedside teaching can be described as a core realistic and successful teaching model (University of Calgary n.d).
Five Step Model:
A five-step model for an effective bedside teaching that has been proposed by the school of cummings, consists of preparation, explanation, teaching, review and self directed learning (University of Calgary n.d).
Step One: Preparation
Suitable patients should be selected for a limited time frame along with the availability of all lab results (University of Calgary n.d). Staff should be informed well ahead of time and patient consent must be taken (University of Calgary n.d).
Step Two: Brief
An advance discussion for the lesson must be made with the students in a peaceful conference room (University of Calgary n.d). This will include quick review of bed side etiquettes, language, clinical examination methods (University of Calgary n.d).
Step Three: Teach
Patients must be made aware of the teaching plan and unrealistic hypothetical scenarios must be avoided in front of the patient to prevent anxiety (University of Calgary n.d).
Step Four: Reflect
Use of SNAPPS for the learning analysis (University of Calgary n.d). Learner should be allowed to summarize the case which will narrow down the differentials so that a careful analysis can be performed then a further probing of the diagnosis and a management plan is made with the selection of arguable issues (University of Calgary n.d).
It is another model to describe the learning environment for the bedside teaching in a hospital setting (Bello et al., 2020). Moreover, since bedside teachings are at a decline due to many reasons such as short patient stay or over worked consultants (Amer et al., 2006) simulation teaching techniques, for example working with fake patients or mannequins and discussions in seminar rooms and corridors are gaining popularity. (Amer et al., 2006) (Bello et al., 2020). Four CARE elements are evaluated while planning such an environment (Carlos et al., 2016). These factors are further explained below after considering simulation and bedside teaching strategies.
Both patients and the learners must be comfortable with the environment (Carlos et al 2016), (Bello et al., 2020), It would be appropriate to pre-plan the visit (Carlos et al 2016). Such planning and patient awareness would help in overcoming any upcoming challenges (Carlos et al 2016), (Bello et al., 2020) An orientation of learners before the visit would reassure them and would help in a better learning of skills such as communication skills, history taking and physical examination (Carlos et al 2016), (Bello et al., 2020) An informed consent by the patient before the visit would help in a rapport development (Carlos et al 2016), (Bello et al., 2020). Such consent would also help in a convenient peer discussion in front of the patient. (Carlos et al 2016), (Bello et al., 2020). Regarding simulation teaching techniques “climate” can be controlled by the preplanned settings and a prior briefing about the scenario (Bello et al., 2020)
In the setting of hospital bedside, patient encounter time must be established (Carlos et al 2016) (Bello et al., 2020). A careful plan must be made before questioning or examining the patient to ensure all learners’ engagement, for a short patient visit and a limited time of discussion in front of the patient (Carlos et al 2016) (Bello et al., 2020). In a simulated session, learners can take their time in learning the skills of choice with the maximum interaction (Bello et al., 2020).
A live interaction in a real scenario can help in a superior development of reasoning and acquiring confidence (Carlos et al 2016) (Bello et al., 2020) On the other hand, a moderator or instructor can participate in interaction for better understanding. (Bello et al., 2020)
Feedback and evaluation can be delayed until the encounter is over and learners are allowed to have some privacy for self reflection (Carlos et al 2016) (Bello et al., 2020) However, during a simulation learning, an assessment can be done simultaneously while practicing and learner is given time to do corrections (Bello et al.,2020).
Since bedside teaching is a distinct instructional method in clinical scenarios, an emergency room teaching is another unusual learning opportunity (Amer et al., 2006). Emergency Department Strategies for Teaching Any Time (EDSTAT) framework provides a highly dynamic training environment (Caners 2015). First, an orientation of the students is important to create a learning expectation, second teacher must diagnose the spontaneous learning deficits so that the weaker skills should be made stronger, third, a teaching set-up must be organised like arrangements of teaching materials, fourth a variety of teaching techniques can be employed, fifth, learners’ simultaneous real-time assessment and lastly an exemplary attitude of the teachers (Caners 2015).
On the whole, although bed side teaching has multiple learning environments such as a vigorous emergency department, slow hospital beds or an artificial simulation lab, every scenario has its limitations that control the framework and learning capacity (Bello et al., 2020).
Following are the strengths:
- Evidence suggests a positive attitudinal shift in learning communication skills utilizing simulated patients in experiential learning methodology (Koponen et al 2012).
- Bedside teaching consuming simulation and standardized patients is readily available. The use of web-based technologies in conducting similar experiential learning opportunities has proven to be helpful (Fink et al 2021; Liaw et al 2016).
- Bedside teaching using standardized patients can be versatile. The use of standardized patients in sensitive male and female uro-genital and breast examination has created teaching opportunities that were not widely available otherwise (Fink et al 2021).
- Simulation is a controlled and safe environment, especially when working in situations that might turn violent or if there is a danger of the spread of infections for instance (Doolan et al 2013).
- The bedside simulated patient technique provides time and space for effective debrief that helps in acquiring required changes in skills and attitudes (Liaw et al 2016).
- Another strength is it is being flexible in use for example it can be used in breaking the bad news, managing an angry patient, disclosing a medical error or acquiring a sufficient sexual history and sensitive male and female uro-genital examination( Hopkins et al 2021).
- The simulated patient methodology has the potential to be evaluated and thus subject to dynamic & continuous improvement (Stacy et al 2008).
- The beauty of bedside standardized patient technique is it is very close to reality (Vest et al 2016). The cognitive and emotional involvement lets the students and residents think and feel very similar to what and how they might have reacted (or felt) in reality.
- Effective on increasing the knowledge, improving comm skills and a lasting behaviour change.M1If we compare the cost that is being born in the absence of such training the medical students and residents, (return of investment), the technology is cost-effective(Vest et al 2016).
- Teaching and learning bedside clinical methods using Standardised patients can never replace the need of interviewing and examining real patients.
- Needs physical space. Moreover, it requires active participation from the faculty. We have recently witnessed that it is not as good in online circumstances as it is in a one-on-one physical setting.
- Although we can utilize SP methodology in bedside teaching, one of the limitations is its relative ineffectiveness in learning operative skills etc.
- We must maintain safe boundaries especially during sensitive examinations, and in conducting interviews that can provoke intense emotions etc.
- Another limitation is that this can only be used in ‘’casual office hours. ‘’ when some of the busy practitioners might not be available for providing sight feedback.
- As we know that the CDM and medical management landscape is continuously evolving, this changing paradigm demands that the changes must be incorporated in congruence with the recent advancement in medical teaching. One such example could be the incorporation of virtual reality in bedside teaching involving SPs.
- Does it carry long-term attitudinal shifts? Where is the evidence?
- As this methodology needs a dedicated space (CLRC), administrative staff, faculty, SP trainers etc. it is relatively costly and poses high logistic demands on the medical education that is already not a top priority for the financing bodies and governments in recent years.
The simulation provides an excellent opportunity to interview and examine the patients without being confused or anxiousM9. It also provides a perfect opportunity to present the learner’s behaviour to the facilitators for optimum interjection and feedback. Simulation provides time place and person to practice communication and management in a controlled environment. We can push its boundaries further by involving virtual reality and other cutting-edge technologies.
As this method of teaching is not the reality! Here is a difference between the actual shock of the reality and a controlled event where the worst could be predicted or anticipated. Could medical students develop behavioural desensitivity on repeatedly being exposed to these simulated environments? ‘’How much the (standardized) patients are involved in decision making about their role in Competency-Based Medical Education ‘’ and how could it change the medical education landscape that involves standardized patients are some of the questions that we can see on horizon.
Moreover, the labour (faculty, SPs etc.) and the logistics seem to be enormous in the wake of recent cuts in the provision of funds to medical education.
Tales from the Field
Regardless of what area of health care individuals have trained, the impact of bedside teaching, both with real and simulated patients, cannot be understated. See below excerpts from the authors regarding their personal experiences with bedside teaching.
“There are countless personal experiences that I can associate with experiential learning while consuming standardized patient methodologies. I can recall one such encounter where a medical student was pointed out by the SP and the faculty about using medical jargon while conducting a focused history and physical examination. Years later the student returned as faculty and shared the usefulness of that encounter and how that helped her in going through so many similar encounters in the real world while in independent practice. She narrated how this incidence and subsequent training shaped her practice in being cognizant of the use of medical jargon in professional communications and the cognitive imprinting that always dominated her word choice and consideration of the audience level and type of understanding while communicating about medical stuff.” -Muhammad Khan
“Bed teaching has its own charm. No matter the amount of practice was performed on fake patients or dummies, encountering a real patient is always a new experience. I remember that in one of my first history taking class with the real patients, my patient didn’t tell everything and when the same question was asked by the professor he gave a better history. That day I learned the value of asking a proper open ended question for a diagnosis.” -Erum Zeb
“The introduction to bedside teaching was gradual and carefully executed during my training in medical school. In the first two years, the majority of our patient interactions were with simulated patients. This provided the learners a safe environment to learn fundamental skills of history taking and physical examination. Frequently, the simulated patients had been performing this role for many years or had experiences being real patients so were able to provide us with feedback of the patients experience of the interaction. As we progressed into our clerkship years, the emphasis of our bedside teaching involved real patients. Our experiences with the simulated patients provided a solid foundation for us to use in our encounters with real patients.” -Jessica Bruce
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