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Explore This IssueApril 2018
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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.