Description of Strategy: An Introduction to Kennel and Stall side Teaching

What is kennel-/stall-side teaching?

In human health professions, bedside teaching is most broadly described as any teaching that occurs in the presence of a patient (Salam, Siraj, Mohamad, Das, & Rabeya, 2011). In a veterinary context stall or kennel side teaching includes teaching done in the presence of the animal and/or the owner. The interactions with both participants require the development of skills and knowledge that can be readily gained in a bedside teaching context.

There is a lack of literature on kennel and stall side teaching in veterinary medicine and there are currently no standards or guidelines for clinical teaching (Conner, Behar-Horenstein, & Su, 2016; see also AVMA 2015). Therefore, most information is extrapolated from human health professions regarding bedside teaching.

What is the value of bedside teaching?

Bedside teaching is a valuable strategy for learning the skills of communication, time management, history taking, and diagnostics (Salam et al., 2011). Bedside teaching offers students an opportunity for social learning by providing instructors the ability to role model professionalism and interpersonal skills (Janicik & Fletcher, 2003). Bedside teaching is also an important method of teaching the basic but invaluable clinical skills of physical examinations and clinical reasoning (Qureshi & Maxwell, 2012).

Why is bedside teaching declining in use?

Over the past 50 years bedside teaching has declined in use (Qureshi & Maxwell, 2012). Clinical training has shifted towards other teaching strategies including simulation, e-learning, case based learning, and small group discussions. Concerns regarding patient comfort and confidentiality, instructor time and teaching ability, increased patient throughput, and increased responsibilities placed on clinicians all contribute to an avoidance of bedside teaching (Qureshi & Maxwell, 2012). Despite this decline students continue to show a preference for bedside teaching and gain significant clinical skills through this educational strategy (Salam et al., 2011).

The causes of the decline in bedside teaching in human medicine are reflected in the veterinary field. Patient comfort is of heightened importance as patients who become stressed and fractious may not tolerate examination and can present a safety risk to all involved. An additional concern for veterinary medicine is the need to take into consideration business and financial aspects. While pet insurance is on the rise most pet owners in North America do not have pet insurance (North American Pet Health Insurance Organization). Financial limitations have been identified as the primary barrier to pet owners accessing veterinary care (Decker Sparks, Camacho, Tedeschi, & Morris, 2017). Involving students in bedside teaching when finances are a limiting factor requires careful management as clients can feel judged or inadequate if communications are not handled with empathy and tact. Veterinary clinicians have additionally identified unpredictable caseloads and students at various levels of understanding as hurdles to kennel side teaching (Smith & Lane, 2015).

Where does bedside teaching occur?

Bedside teaching is often thought of as occurring in hospital settings only. In fact, bedside teaching can occur in any setting that includes a patient or client (Janicik & Fletcher, 2003)

What does bedside teaching look like?

Bedside teaching can take on many different forms from unplanned to highly regimented. Janicik and Fletcher (2003) describe one approach to bedside teaching that begins outside the room where consent is obtained and roles, goals, and time limits are established. After entering the room introductions are made followed by diagnosis, focused teaching, discussion, feedback, and finishing with addressing any further patient questions. After leaving the room a private debrief with feedback is conducted.

The 5 Step Microskills Model can also be used as a framework for bedside teaching (Neher, Gordon, Meyer, & Stevens, 1992). This microskills model breaks bedside teaching down into manageable tasks and can be adjusted based on different situations. The five skills are:

1. Get a commitment
2. Probe for supporting evidence
3. Teach general rules
4. Reinforce what was done right
5. Correct mistakes

By utilizing clear approaches to bedside learning instructors can increase the quality of the learning, increase patient comprehension of their health status, and decrease their own concerns regarding teaching ability, thus eliminating two common barriers to bedside teaching (Janicik & Fletcher, 2003; see also Salam et al., 2011).

Learning Environments

What situations are bedside teaching most suited for?

In veterinary medicine, the learning environment for which bedside teaching is most suitable is the undergraduate curriculum. Bedside teaching occurs principally in the last year of the program with the objective of allowing students to problem solve by applying their basic science and clinical knowledge to real case (Smith, 2003).

Bedside teaching is effective for learning outcomes focused on the humanistic aspects of veterinary medicine including communication skills, professional attitude, and demonstrating empathy, as well as on the diagnostic process, clinical skills, and patient care (Peters & ten Cate, 2014; see also Qureshi & Maxwell, 2012; Salam et al., 2011). By teaching all these skills in a single setting, bedside teaching also shows how to incorporate multiple skills into a comprehensive practice. Janicik and Fletcher (2003) discuss how bedside teaching allows for role modelling of skills including professionalism and interpersonal skills. Patient-centered care is emphasized because of this role modeling and due to the inclusion of the patient and client in the teaching process. Effective role modelling requires skill in high level patient care as well as personal abilities including humility, self-confidence, and patience (Smith & Lane, 2015).

Bedside teaching is considered one of the most effective strategies to teach history taking and physical examination (Jayakumar, 2017; see also Peters & ten Cate, 2014; Bokken, Rethans, Scherpbier, & van der Vleuten, 2008). As advances in technology continue to provide a wide array of diagnostic tools and aids, these basic abilities are easily overlooked in the educational process if bedside teaching is not utilized effectively.

Furthermore, communicating with real clients and practicing medical ethics is best done in a bedside teaching environment where learners can use most of their senses, thereby deepening their learning experience (Peters & ten Cate, 2014; see also Salam et al., 2011). Within the veterinary context, learning to work within economic constraints is another important objective which is best modelled in a kennel or stall side teaching environment (Carr, Kirkwood, & Petrovski, 2021). While financial discussions can be uncomfortable for both clinicians and students this skill must be taught prior to graduation or students will be unprepared for the realities of the field.

For these reasons, the most suitable learning environment is one that is considered a ‘real work context’ and where the patient or client is present (Carr et al., 2021; see also Salam et al., 2011)). Although a hospital setting is the most immediate environment associated with literature on bedside teaching, any setting that includes direct interaction with a patient/client should be considered bedside teaching ( Salam et al., 2011; see also Janicik & Fletcher, 2003).  This includes ambulatory settings, conference rooms, and telecommunications and in veterinary settings can be expanded to include clients’ farms and homes, mobile units, and temporary “pop-up” clinics in addition to more traditional care settings.

What makes for an effective bedside teaching environment?

In addition to considering the objectives for which bedside teaching is most suited, it is also important to consider the physical and affective environment in which these objectives can be achieved.

Considering the decreasing frequency of bedside teaching it is important to implement effective and efficient bedside teaching strategies to motivate educators to continue using this methodology. Carlos et al. (2016) proposed four aspects of a meaningful bedside teaching environment:

• Climate: Ensure the patient/client and the learner are comfortable by explaining everyone’s role, clarifying expectations and what may be assessed, and ensuring patient consent to participate in the teaching situation has been obtained (Carlos, Kritek, Clay, Luks, & Thomson, 2016). Encourage patient/client questions and emphasize that conversations may happen between the learner and the teacher that do not directly pertain to the patient/client. Remind learners to avoid medical jargon.
• Attention: Organize the encounter with a focused approach and time limits to prevent a drawn-out process and minimize the potential for distractions (Carlos et al., 2016). Apply strategies that engage all learners to avoid disengagement.
• Reasoning: Teaching clinical reasoning is a major objective of using a bedside teaching strategy (Carr et al., 2021). The teacher’s goal is to determine whether learners understand and can rationalize the symptoms, diagnostics, and treatment approaches in the patient of concern(Carlos et al., 2016). Asking questions on behalf of the patient/client and asking probing questions are ways to tease out clinical reasoning ability in learners.
• Evaluation: A benefit of bedside teaching is the ability to provide and receive immediate feedback (Salam et al., 2011). This is particularly valued by learners (Bokken et al., 2008). As highlighted by Carlos et al. (2016), immediate feedback should focus on specific behaviors such as an improperly performed physical examination. More critical comments must be delivered in private after the patient interaction to safeguard learner’s dignity and trust in the teaching process. Delayed feedback allows the learner to reflect on the experience and provide potential solutions for an improved process with a subsequent patient encounter.

Bedside teaching lends itself well to implementing a reflective learning component such as Kolb’s learning cycle (Kolb 1983). Kolb’s cycle is based on a concrete experience such as a patient encounter followed by reflective observation, abstract conceptualization, and active experimentation. In bedside teaching these four components could be a patient encounter, delayed feedback, teaching general rules, and then following up with another patient encounter. Used this way, bedside teaching promotes reflective practice in the learner which encourages engagement and innovation while assigning learning responsibility to the learner.

Is bedside teaching a necessary component of veterinary medical education?

In 1903, Sir William Osler stated: “To study the phenomena of disease without books is to sail an uncharted sea, whilst to study books without patients is not to go to sea at all.” (Osler, Silverman, Murray, & Bryan, 2002). One could argue that learning resources at the beginning of the 20th century were markedly more limited than in the 21st century and that Osler’s statement may no longer hold true today. However, Salam et al. (2011) believe that “bedside teaching cannot be replaced by anything else”; Peters and ten Cate (2014) state that “certain aspects of physical examination can hardly be learned in any other way than with real-life practice” and Jayakumar (2017) highlights that “simulators are limited in their ability to mimic real physical signs”. Furthermore, Qureshi and Maxwell (2011) emphasize that bedside teaching provides trainees with a first-hand understanding of a doctor-patient relationship that allows them to experience the human impact of disease.

To highlight a veterinary medicine specific situation, sun, snow, rain, flies, and dust regularly encountered by a large animal clinician traveling from farm to farm are working conditions that cannot be simulated well (Smith, 2003). The management of these situations must be learned in real life to be understood. Smith (2003) also emphasizes the benefit of subjecting students to different clinical experts, working in varying ways, and exposing trainees to different perspectives which can elevate their own clinical practice.

These examples strongly support the use of bedside teaching. Alternatives such as high-fidelity simulation provide other unique learning opportunities with benefits such as allowing multiple repetitions to practice a skill and providing a low-stress environment in which students may be more comfortable with their mistakes (Jayakumar, 2017; see also Peters & ten Cate, 2014).

Is there evidence that bedside teaching is superior to other teaching strategies?

There is minimal literature focused on actual approaches to bedside teaching or evidence of its potential superiority over other teaching strategies. One study aimed to determine whether bedside teaching, either taking a demonstration and practice (DP) or a collaborative discovery (CD) approach, would increase students’ clinical examination skills and ability to identify key clinical features (Smith et al., 2006). This was looked at both in comparison to each other and with a control group. DP is considered the classical approach to bedside teaching (Peters & ten Cate, 2014). DP consists of trainees performing a skill, reporting their findings back to the group, the teacher confirming or correcting the findings and demonstrating the skill correctly if necessary. At the end of the session all trainees practice the skill. In contrast, in CD, all trainees perform the skill and report their findings back. The teacher’s role consists of summarizing the reported findings and emphasizing overlap and discrepancies. Following the teacher’s input on skill performance, all trainees practice again until they reach a consensus in their findings (Peters & ten Cate, 2014). In the study by Smith et al. (2006), both bedside teaching approaches significantly improved students’ ability to perform the clinical technique and CD resulted in significantly more students identifying key clinical features in comparison to control group students. The authors concluded that bedside teaching was a superior strategy to teaching the clinical skill but there was no difference between the two approaches. Other studies provide evidence of at improved scores or diagnostic decision-making ability when trainees had exposure to bedside teaching but differences between groups were not always statistically significant (Peters & ten Cate, 2014). From a patient safety and quality improvement perspective, any tendency to increase the number of correct diagnoses or clinical examination findings is probably clinically relevant.

Understanding the value and limitations of the various teaching methods available in experiential learning allows teachers to utilize the most appropriate method. The following SWOT analysis of kennel and stall side teaching explores the strengths and weaknesses of this teaching strategy.

SWOT Analysis

Strengths

Kennel/stall-side teaching on the clinic floor in veterinary medicine provides an opportunity for learners to apply the knowledge that has been provided to them in didactic and laboratory studies in their first three years of veterinary study. This setting provides learners with a variety of teachers including faculty members or clinical associates, technicians, house officers including interns and residents, and other students (Stefanou, Moore, Semper, Conner, McConkey, & Aherne, 2019). Kennel/stall-side teaching allows for various teaching techniques to be applied including knowledge exchanges, clinical reasoning, feedback, and demonstrations and application of professional competencies (Stefanou et al., 2019). There are also frequent teaching opportunities where the teacher can help solidify and apply the knowledge gained in the classroom.

Weaknesses

There are a variety of weaknesses when it comes to kennel/stall-side teaching in veterinary medicine. One is the lack of educational training of the faculty as well as the house officers (Lane & Strand, 2008). This means that undesirable teaching techniques are observed such as lack of explanation of clinicians’ reasoning or student correction and nonverbal confirmations. Although these were observed less frequently, they were still present (Stefanou et al., 2019).

Another weakness is the logistics of teaching in a hospital or clinic setting. The busy caseload provides students plenty of learning opportunities, but it also pulls the clinicians out of the teaching role as they must worry about patient and client care. This setting may also provide a suboptimal learning environment. Distractions such as a busy, loud, or tense environment may add extra anxiety and affect the performance of the learner. Faculty are often specialized in their area which provides students with an excellent resource of knowledge but does not always provide students with the reality of general practice. The cases that are referred do not always mimic the cases they will be seeing (Stefanou et al., 2019). Clinicians’ attention is also often pulled in multiple directions including didactic teaching, research and administration needs on top of clinical responsibilities (Stefanou et al., 2019).

Although kennel/stall-side teaching in the clinic has the expectation of the student taking the role of the veterinarian, students are still often taking the role of the observer (Stefanou et al., 2019). In experiential learning, reflection is part of the process (Kolb, 1983) but in the authors’ experience unless specific time is set aside to allow the students to reflect this step is often overlooked or skipped entirely.

Opportunities

Despite the weaknesses, cage/stall-side teaching provides learners with opportunities to gain real life experience, interact with clients, and experience the ambiguity and art of veterinary medicine that is difficult to teach in a didactic setting (Conner et al., 2016). Learners are provided with opportunities for reflection and debrief on their experiences at the stall/cage-side, both in the positive as well as the negative. The cage/stall-side experience also provides for peer-to-peer teaching as students come with varying life and veterinary experiences. It provides opportunities for higher level thinking such as analyzing data, evaluating the patient, and creating diagnostic and treatment plans (Carr et al. 2021).

Threats

Unlike a classroom setting, the clinic floor is unpredictable in terms of the patients that will come in, client interactions, and teachable moments. Veterinary medicine currently has a shortage of veterinarians as well as veterinary technicians. Not only does this have ramifications on the number of people in the teaching role for students, but it also increases the risk of using students for different tasks that are not as learning focused. Anecdotally, the authors have also experienced a shift in client perceptions and expectations. These include an unwillingness to be involved in the teaching process, at least partly because of concerns over their pet’s welfare and because of the expectation for high quality, efficient service by an expert.

“Tails” from the Field

Emilia Wong Gordon is the Senior Manager of Animal Health at the BC SPCA and the first board certified Shelter Medicine practitioner in Canada. The following is her reflection on bedside teaching in community medicine.

“I have been involved in bedside teaching in community medicine settings for over 20 years (free clinics for pet guardians experiencing homelessness) – starting when I was a student, and now as a veterinarian teaching students. These clinics typically rely on volunteer professionals (including students) in order to offer pet food, wellness care, and other basic services. They provide valuable One Health support to marginalized community members who have pets. While there are public health benefits, including the provision of vaccines and parasite control and reduction in human-directed food fed to companion animals, the value of these clinics goes well beyond these.

At these clinics, the human-animal bond is front and centre. The clients, often people who we pass on the street and look away, are met by students as people with stories and lives. There is no “treatment area” to which the animal can be taken away; the client is present for all services. The client, who often spends 24 hours a day with the animal, is the expert on their animal. As the student engages with the client, they respect the client as a participant and partner in the animal’s care. They both experience relationship-centred care without the formal setting of a veterinary office with its intimidating equipment and discussions of billing. The student must rely on their physical examination and history-taking skills to formulate a plan; it is a place where compassion meets the art and science of medicine.

A few years ago, I took a 4th-year veterinary student to our free clinic and there we treated an older cat who presented for a “lump on her belly.” She had never been spayed. The examination revealed extensive mammary masses; these were undoubtedly malignant mammary carcinoma, and the cat’s long-term prognosis was grim. We had to tell this owner, in the middle of a crowded free clinic and without any diagnostics, that her cat was going to die soon. Of course, she became very upset and cried. We went through our limited supply of pain medications (reviewing which medications might have some anti-neoplastic activity) to offer what we could to keep the cat comfortable and told the owner she could come to the non-profit hospital when the time came to euthanize. The student sat with her and made her feel like the only person in the room. At the end of the visit, the owner spent several minutes praising the student and wishing the best with her education.

These clinics are often the students’ first exposure to the concepts of harm reduction and the social determinants of health (which affect people and companion animals together); important concepts for them as they go out into the world to practice. Students are often apprehensive prior to the clinics, but by the time the clinic is over they are energized and engaged. These clinics provide an opportunity to assess the students’ clinical and communication skills, but most of all these opportunities facilitate learning that disrupts our traditional, paternalistic models of medicine. Both the students and clients gain confidence and are empowered in this learning model. There are potential safety drawbacks that need to be managed, and it’s important for the students not to view the animals as simply there to create “practice” opportunities or to have biases about marginalized people reinforced by the experience- the attending clinician must manage these risks.

Ultimately, bedside teaching in a community medicine setting allows us to connect to the reason we entered the profession, to create opportunities for students to gain trust in clients as collaborators and their own clinical abilities, to humanize people who regularly experience dehumanization, and to instil a compassionate spark in students that hopefully will last throughout their careers. There are few experiences in veterinary school with the potential to hold this much meaning.”

Chris Clark is the Associate Dean of Academic Affairs at the WCVM. He is also a board-certified large animal veterinary internist with over 20 years of experience teaching. In this testimonial, he highlights a particular challenge he encounters when teaching stall side.

“To me the hardest thing about stall side teaching is to avoid my most common pitfall. It is far too easy for the discussion about the patient to devolve into the students asking me questions about the case; this is exceptionally easy for them and far too easy for me to get stuck in a rut. What I need to do is ask them questions and then let them talk! They need to understand the case and take the responsibility of determining the right diagnostic approach and developing the correct treatment plan. Furthermore, when it works well you let the students see that you are following their suggestions and making them see that if it doesn’t work that it will be on them (obviously you do provide a safety net). The hardest thing for me is to do this in a conversational style that forces the student to think without simply saying “why?” to every comment that they make! I have known several individuals who do this well and make it look effortless, I wish that I could do it better.”

References

American Veterinary Medical Association (AVMA) (n.d.). COE accreditation policies and procedures. Retrieved October 19, 2021 from https://www.avma.org/education/accreditation-policies-and-procedures-avma-council-education-coe/coe-accreditation-policies-and-procedures-requirements

Bokken, L., Rethans, J. J., Scherpbier, A. J., & van der Vleuten, C. P. (2008). Strengths and weaknesses of simulated and real patients in the teaching of skills to medical students: a review. Simul Healthc, 3(3), 161-169. doi:10.1097/SIH.0b013e318182fc56

Carlos, W. G., Kritek, P. A., Clay, A. S., Luks, A. M., & Thomson, C. C. (2016). Teaching at the bedside. maximal impact in minimal time. Ann Am Thorac Soc, 13(4), 545-548. doi:10.1513/AnnalsATS.201601-018AS

Carr, A. N., Kirkwood, R. N., & Petrovski, K. R. (2021). Using the five-microskills method in veterinary medicine clinical teaching. Vet Sci 8(6), 1-14. Retrieved from https://www.mdpi.com/2306-7381/8/6/89#

Conner, B. J., Behar-Horenstein, L. S., & Su, Y. (2016). Comparison of two clinical teaching models for veterinary emergency and critical care instruction. J Vet Med Educ, 43(1), 58-63. doi:10.3138/jvme.0415-069R1

Decker Sparks, J. L., Camacho, B., Tedeschi, P., & Morris, K. N. (2017). Race and ethnicity are not primary determinants in utilizing veterinary services in underserved communities in the United States. J Appl Anim Welfare Sci, 21(2), 120-129.  https://doi.org/10.1080/10888705.2017.1378578

Janicik, R. W., & Fletcher, K. E. (2003). Teaching at the bedside: a new model. Med Teach, 25(2), 127-130. doi:10.1080/0142159031000092490

Jayakumar, N. (2017). Bedside teaching with unwell patients: Can it ever be appropriate? Med Teach, 39(3), 323-324. doi:10.1080/0142159X.2016.1248922

Kolb, D.A. (1983). Experiential learning: experience as the source of learning and development. Upper Saddle River, NJ: Prentice Hall.

Lane, I. F., & Strand, E. (2008). Clinical veterinary education: insights from faculty and strategies for professional development in clinical teaching. J Vet Med Educ, 35(3), 397-406. doi:10.3138/jvme.35.3.397

Neher, J. O., Gordon, K. C., Meyer, B., & Stevens, N. (1992). A five-step “microskills” model of clinical teaching. J Am Board Fam Pract, 5(4), 419-424. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/1496899

North American Pet Health Insurance Organization, Section 2: Total Pets Insured (n.d.) Retrieved October 19, 2021from https://naphia.org/industry-data/section-2-total-pets-insured/

Osler, W., Silverman, M. E., Murray, T. J., & Bryan C. S. (2002). The quotable Osler. Philadelphia, PA: American College of Physicians.

Peters, M., & ten Cate, O. (2014). Bedside teaching in medical education: a literature review. Perspect Med Educ, 3(2), 76-88. doi:10.1007/s40037-013-0083-y

Qureshi, Z., & Maxwell, S. (2012). Has bedside teaching had its day? Adv Health Sci Educ Theory Pract, 17(2), 301-304. doi:10.1007/s10459-011-9308-1

Salam, A., Siraj, H. H., Mohamad, N., Das, S., & Rabeya, Y. (2011). Bedside teaching in undergraduate medical education: issues, strategies, and new models for better preparation of new generation doctors. Iran J Med Sci, 36(1), 1-6. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/23365470

Smith, B. P. (2003). Teaching the art of clinical practice: the veterinary medical teaching hospital, private practice, and other externships. J Vet Med Educ, 30(3), 203-206. doi:10.3138/jvme.30.3.203

Smith, C. A., Hart, A. S., Sadowski, L. S., Riddle, J., Evans, A. T., Clarke, P. M., Ganschow, P. S., Mason, E., Sequeira, W., & Wang, Y. (2006). Teaching cardiac examination skills. A controlled trial of two methods. J Gen Intern Med, 21(1), 7-12. doi:10.1111/j.1525-1497.2005.00254.x

Smith, J. R., & Lane, I. F. (2015). Making the most of five minutes: the clinical teaching moment. J Vet Med Educ 42(3), 271-280. doi:10.3138/jvme.0115-004R

Stefanou, C., K., Moore, J., Samper, B., Conner, M., McConkey, M., & Aherne, M. (2019). Part II: Observations of clinical teaching in the veterinary teaching hospital. Health Prof Educ 2, 91-97. DOI:10.4103/EHP.EHP_19_19