How & Why Attending Physicians Should Teach in Patient Rooms

No matter where you practice, rheumatology clinics are extremely busy. And in that hustle and bustle we find an uncomfortable jostling of priorities between delivering optimal care for as many patients as possible and upholding education for teachers and learners at all levels. Because salary usually comes from seeing more and more patients, teaching is often left behind, which is a horrible shame for learners, teachers and, ultimately, patients.

But to me, if the question is time, the answer is space. Teaching in the patient’s room is a longstanding tradition in American medical education that’s slowly regaining favor years after being discarded as too old-fashioned. In addition to saving time by reducing redundancy, it offers plenty of other benefits, many of which have been upheld by studies.^1-4 If done correctly, it can minimize the conflict between service and teaching, may lead to unexpected and fruitful outcomes, and can provide several benefits, including the following:

1. It Improves Patient Satisfaction

Patients, for the most part, love to be in the know. In my experience, they like to learn alongside medical professionals. Many deeply appreciate the time and effort it takes to educate one another in the medical field. Incorporating them into the teaching environment dignifies and justifies their visit to an academically inclined clinic. At the very least, it provides something for them to engage in, instead of waiting patiently for the attending physician to come in and briefly say a few words.

It also provides patients an opportunity to look behind the scenes, to figure out how symptoms and signs come together as part of a diagnosis. Because bedside teaching highlights the attending’s role as a leader, it can improve rapport and the patient–physician relationship as well (so long as bedside teaching occurs appropriately). Given that our compensation is increasingly driven by satisfaction, bedside teaching may be a suitable strategy to increase those infamous Press-Ganey scores, all while improving service and teaching.

2. It Places Focus Back on the Clinical Examination

By having patients nearby, teachers can highlight methods of examination and inspection in a hands-on manner. The clinical examination’s quality can be rigorously analyzed, and results can be scrutinized when making diagnostic decisions.

In addition, bedside teaching provides ample opportunities to show how to perform physical examinations, and to point out poor technique. It’s one thing to discuss the steps of a shoulder examination; it’s quite another to do it with the learner and interpret the findings in real time. This creates a rich and rewarding environment for learners, and even for teachers, who become more than just supervisors but role models, too.

3. It Highlights Diagnostic Decision Making

Even tougher than teaching the clinical exam is highlighting diagnostic decision making. In large part, this is because sound decision making demands incorporation of several compression inputs in order to reach an assessment and plan. Many inputs are subtle—maybe the feel of bogginess in the hands leaves a distinct impression, for example, compared to simply hearing a patient has second MCP swelling. Maybe a hint of hesitation in a patient’s voice will open a conversation about adverse effects and therapy modification. By moving the diagnostic reasoning setting to the patient’s room, then, these inputs can occur true to form. In the right context, the teacher can even probe how a learner is synthesizing information and make valuable suggestions to improve their method of putting signs and symptoms together.

4. It’s Billable

One nuance of billing and coding is that if you’re billing by time, the attending must be present, and more than 50% of the encounter must be devoted to the counseling and coordination of care. Sadly, resident and fellow time doesn’t count. Therefore, if a patient requires a lot of education (such as for fibromyalgia) and requires medically necessary laboratory or radiographic workup, it may prove far more productive to sit in the room and receive credit for what you intend to do anyway. And at the same time, if the attending is actively engaged, it allows opportunities for quiet observation and feedback.

5. It Provides Opportunities for Observation

Perhaps the most valuable aspect of bedside teaching is that it provides opportunities to not only increase the amount of observation time, but also improve the quality of observation. Indeed, the art of observation is more than just passive action; it’s a clinical skill that’s vital for educators. The more you observe, the more you can observe.

On quiet days, I sometimes sit through an entire interview between learner and patient. I take a piece of paper and write down my thoughts and observations like an impassionate fly on the wall. These notes become the basis for later feedback, making it structured and objective.

In contrast, on busier days, I sometimes work as the scribe and type the current illness history as the learner talks, helping me maximize my productivity both inside and outside the clinic. And I can learn, too, by picking up on habits my learners have acquired and cultivated from other sources.

Concerns & Qualifiers

Of course, not all clinical encounters should be precepted in the exam room. Difficult patients may need a singular provider to talk to. But by and large, even difficult patients provide opportunities for learning and teaching in the room. Although uncomfortable, it provides a window to assess professionalism and interpersonal communication skills. The only caveat? Fellows and residents should provide attendings a heads-up prior to entering a difficult patient’s room so the attending can take it into account.

Another concern: putting learners on the spot and taking away their autonomy. When bedside teaching is done poorly, this is a tremendous problem, but some deference and common sense go a long way towards resolving these problems. I recommend using a light touch and allow fellows to engage with their patients as much as possible. This depends on each learner, but I essentially let the second-year fellows have free rein. If there’s a difference in opinion or a necessary course correction, I make it clear I work as a consultant to provide evidence or an opinion to the contrary, and I let the learner dictate the course of action. This provides two added bonuses of 1) incorporating evidence-based medicine into practice, and 2) elevating the status of learners as independent physicians in the patient’s eyes.

Admittedly, teaching in the room requires flexibility, accommodation and dedication. But it’s worthwhile and helps harmonize clinical service and teaching. Moreover, it better approximates what medical education should be—a slow and gradual substitution of the attending’s visible and palpable presence in the room with the learner’s own judgment and reasoning.

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Bharat Kumar, MD, MME, FACP, RhMSUS, is the associate program director of the rheumatology fellowship training program at the University of Iowa in Iowa City. He completed a dual fellowship in rheumatology and allergy/immunology, and a master’s in medical education in 2017. He has special interests in journalism, healthcare policy and ethics. Follow him on Twitter @BharatKumarMD.

References

1. Chapman R, Wynter L, Burgess A, et al. Can we improve the delivery of bedside teaching? Clin Teach. 2014 Oct;11(6):467–471.
2. Petersen K, Rosenbaum ME, Kreiter CD, et al. A randomized controlled study comparing educational outcomes of examination room versus conference room staffing. Teach Learn Med. 2008 Jul–Sep;20(3):218–224.
3. Anderson RJ, Cyran E, Schilling L, et al. Outpatient case presentations in the conference room versus examination room: Results from two randomized controlled trials. Am J Med. 2002 Dec 1;113(8):657–662.
4. Rogers HD, Carline JD, Paauw DS. Examination room presentations in general internal medicine clinic: Patients’ and students’ perceptions. Acad Med. 2003 Sep;78(9):945–949.