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.
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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.
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.
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