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ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 1-13

Residents and teaching physicians' perception about bedside teaching in non-clinical shift in the emergency department of King Abdul-Aziz Medical City, Jeddah, Saudi Arabia


Emergency Department, King Abdulaziz Medical City - National Guard, Jeddah, Saudi Arabia

Date of Web Publication8-Jan-2018

Correspondence Address:
Azzah Aljabarti
Emergency Department, King Abdulaziz Medical City - National Guard, P. O. Box 9515, Jeddah 21423
Saudi Arabia
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DOI: 10.4103/jhs.JHS_6_17

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  Abstract 

Introduction: Bedside teaching (BT) is teaching in the presence of the patients which allows direct observation of the learner. It is a very crucial educational modality, which has declined significantly over the last decades. It is under-utilised and under-studied in Emergency Medicine. Although time constraints in the emergency department (ED) is associated with efficient and effective patient management; it exerts a negative influence on the time spent on bedside teaching.
Objective: To determine the residents' and teaching physicians' (TPs') perception about BT in non-clinical shift regarding: Clinical knowledge, data gathering, procedure performance, communication and constructive feedback.
Methods: Quantitative, cross-sectional study was done at King Abdulaziz Medical City, ED. Two groups were formed: (learners N=30) and (TP N=20) total N=50. We used self-administered questionnaire and then the data was analysed using SPSS version 20.0. Demographic data and results were expressed by mean ±SD and percentage. Comparison was then made between the two groups by using T-test (P < 0.05).
Results: There were 50 participants in this study and 100% filled the questionnaires. All 20 (100%) of TP have previous experience with BT vs. only 17 (58%) of the learners. The residents and TPs responded to benefits of the BT: on clinical knowledge with mean values of (4.63±0.41 vs. 4.76±0.37) respectively and on data gathering with mean values of (4.73±0.51 vs. 4.24±0.97) respectively. Forty-six percent of the learners and 20% of the TPs responded to the benefits on procedures; however, the mean values of (4.93±1.0 and 5.0±0.01) were reported from the residents and TPs respectively. Regarding communications, we got mean values of (4.65±1.25 vs. 4.18±0.46) respectively. In regards to giving constructive feedback, the two groups' perceptions gave mean values of (4.58±1.01 vs. 4.57±0.8) in the residents group vs. TPs.
Conclusion: Based on the review of the learners and the TPs' perception, we concluded that BT in non-clinical shift is very effective to improve the learners' clinical knowledge, data gathering, communication skills and facilitates giving constructive feedback. However, the benefits regarding procedure performance is still an area that needs further investigation.

Keywords: Bedside teaching, emergency medicine, non-clinical shifts


How to cite this article:
Aljabarti A. Residents and teaching physicians' perception about bedside teaching in non-clinical shift in the emergency department of King Abdul-Aziz Medical City, Jeddah, Saudi Arabia. J Health Spec 2018;6:1-13

How to cite this URL:
Aljabarti A. Residents and teaching physicians' perception about bedside teaching in non-clinical shift in the emergency department of King Abdul-Aziz Medical City, Jeddah, Saudi Arabia. J Health Spec [serial online] 2018 [cited 2018 Jul 22];6:1-13. Available from: http://www.thejhs.org/text.asp?2018/6/1/1/222465


  Introduction Top


'For the junior student in medicine and surgery, it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself' – Sir William Osler, addressed to New York Academy of Medicine, 1903.[1]

'Medicine is learned best by the bedside, not in the classroom' – Sir William Osler Quotes.[1]

Bedside teaching (BT) is a very crucial teaching modality in medical education. In Emergency Medicine, it is considered one of the most important and effective tools, because this is a speciality that cannot be learnt in the classroom alone and, not to mention, that the learning needs special skills and environments.[2] However, it has a limited role and can be a challenge in a busy shift where both the consultant and/or the resident are distracted from teaching and learning.[3]

BT refers to learning that occurs in the presence of a patient.[4] It allows direct observation of the learners' patient interaction as well as clarification of history and physical examination, by a teaching physician (TP). BT also provides an opportunity to develop and/or affirm the learners' clinical skills in addition to direct evaluation and feedback.

BT has declined significantly over the past few decades,[4] due to the presence of a number of barriers related to the teacher, system and patients, as well as the preferences and dominance of traditional educational methods such as didactic lectures or lecture-based teaching.[4],[5]

Peters and Ten Cate conducted a literature review published in 2013 about BT in medical education to reveal the strengths of BT, causes of its decline and future perspectives. They found several reasons including increase in time constraints of the physicians. BT has shown to improve certain clinical diagnostic skills in the learners, either medical students or residents, and is still valued for them. They came up with strong recommendations to overcome the barriers; in fact they have gone to the degree of considering residents and interns as bedside teachers.[6]

Emergency Medicine is one of the areas which has had a significant decline and underutilisation of this teaching modality;[2],[5] besides it is under studied with only few publications on this regard. The emergency department (ED) is an excellent place for BT.[3] It offers a multitude of patients per shift, full of interesting clinical findings, logistical problems and it allows rapid identification of areas for improvement as well as possibility of direct observation.[7]

Shayne et al., developed an assessment tool to evaluate a program me of 'academic attending teaching shift' in achieving educational objectives.[8] They found that a teaching shift (TS) is effective in meeting the educational goals of academic education.[9]

In 2006, Celenza and Rogers developed a formal BT programme where the physician and resident were freed from clinical duty if the shift was well covered. They found that this affected clinical reasoning the most and procedural skills the least.[2]

Aldeen and Gisondi reviewed common impediments to effective BT in the ED and offered practical strategies to overcome barriers. They found that BT is time-tested but can still be challenging in a busy clinical shift and needs certain strategies to overcome these challenges.[4]

Ahmed, in 2010, summarised the decline in BT in general to factors related to the teaching methods, teachers, students and patient related in particular. Then, he came up with strategies to improve BT by recommending that BT is started at the undergraduate level of medical schools.[10]

In my practice, in a usual ED shift, I find it extremely difficult to sit and observe the learner taking full-detailed history, performe examination and then discuss the treatment plan with the patient. Everybody is under the time pressure in addition to the unpredictable distraction, which might be annoying to the patient, TP and learner.

It is not uncommon when I try to be at the bedside with a learner and a patient in a regular shift, and find that the learner starts to look stressed and uncomfortable because he/she is afraid of making mistakes.

The rationale behind this study is to control one of the most common reasons in the decline of BT in ED, which is the time factor,[6],[10],[11] by conducting a BT in non-clinical shift and then looking at the perception of both the learners and teachers regarding the benefits of this teaching modality.

Constructive feedback, on the other hand, might be a challenge in a busy shift, although limited information about residents and the physicians is available on their perception about it.[12] There is a lack of standards as to how much feedback is necessary to achieve effective clinical teaching.[12]

Effective feedback is one of the major aspects that needs special focus from both sides (residents and TPs) to observe if this teaching modality has a major impact. However, there is lack of time for both to have a satisfying constructive feedback.[13],[14],[15]

On the other hand, formal training in BT needs to begin in EM residency programme to secure the future of trainees' skills, and hopefully, by this study, we will have better support to establish it.

Hence, this research focuses on one of the barriers, which is time constraint, by scheduling a protected teaching time for both the faculty and the residents, called a non-clinical shift, away from the pressure of the clinical shift. Following this, the residents' and teachers' perception was assessed in regards to improvement in the residents' practical clinical knowledge, physical examination, communication and procedural skills,[2] with constructive feedback at the end of each session.

Definitions

  • BT: It is teaching in the presence of the patients;[7] it allows direct observation for residents' clinical skills, procedures and their interaction with patients
  • TP: All the physicians participating in BT (consultants, associate and assistant consultant)
  • TS: It is a shift where both the residents and TPs are scheduled for teaching only with no added clinical responsibilities.


Aim

The main aim of this study was to identify the benefits of BT by creating non-clinical/TS.

Objectives

The main objective of this study was to determine the perception of the ED trainees and their TP regarding the educational and clinical benefits of BT in designated TS, by controlling the time factor, on these areas: clinical knowledge, data gathering, communications, procedure performance and getting and giving constructive feed back.


  Methods Top


This is a quantitative study to evaluate the perception of the BT in a non-clinical shift. It was conducted in the ED at King Abdulaziz Medical City, Western region, over a 3-month period, from August to November 2013. This department is accredited by the Saudi Commission for Health Specialties, as a training centre with more than 70,000 annual visits. It has a total of 35 beds which includes: critical care, intermediate care and rapid assessment zone beds, obstetrics and gynaecology bed and minor procedure room.

Sample

We used a simple purposive sampling technique - all interns and residents in the ED as well as the faculty working over the same period were enrolled in this study. The trainees' group consisted of 30 participants and the TPs group consisted of 20 participants.

Variables

Independent variables

BT in a non-clinical shift.

Dependent variables

The trainees' and TPs' perception about the improvement in:

  • Clinical knowledge
  • Data gathering
  • Communication
  • Procedure skills
  • Time for feedback


Instrumentation

We used two different self-administered questionnaire forms: Form 1 for trainees and Form 2 for TPs [Appendices 1 and 2] [Additional file 1] [Additional file 2].

Process

Approval for the study was sought and granted by King Abdullah International Medical Research Center and the Institutional Review Board committee. We obtained permission from the ED chairman to allow the physicians to conduct the BT in a non-clinical shift.

Before starting to schedule the TSs, we had two introductory brief presentations for each group separately, to explain the purpose of the study and how it should be conducted in addition to guidelines about constructive feedback. Then, the trainees and TPs gave written informed consent to participate in the study.

It was an 8-h shift in which the TP chose the case for learning based on the plan, and the TP selected a few additional teaching points on common emergency cases.

Then, the trainee and the TP interviewed the patient together after receiving his or her permission as a verbal consent. At the bedside, the patient and trainee had minimal interruptions from the TP. Then, the trainee and TP met to discuss the case and review all patient-related data, for example, the laboratory tests or radiographs as well as the management of each case as an evidence-based approach. At the end of the session, there was formal feedback about the trainee's performance and the session from different aspects. Each participant was asked to complete the assigned questionnaire. All the forms were kept in a sealed envelope and given to the assigned coordinator.

Statistical analysis

For data analysis, descriptive statistical methods including frequencies, percentages and means ± standard deviation have been used to measure and to understand sample responses.

A t-test was used as a method of comparison to detect if there is significant variation between the two samples' perception. A P ≤ 0.05 was considered statistically significant.

Before collecting data, we checked the reliability of the questionnaire to make sure that the method used in data collection was reliable to achieve the main objectives of the research. Cronbach's alpha coefficient was used to measure the reliability statistics:

Form 1: (trainees' perception)

  • Number of items (41)
  • Cronbach's alpha coefficient (0.995) >0.70


Form 2: (TPs' perception)

  • Number of items (40)
  • Cronbach's alpha coefficient (0.976)


Therefore, both forms 1 and 2 have achieved a high reliability.


  Results Top


Fifty-five trainees and TP were approached with fifty agreeing to participate. Thirty trainees (30), that is, 90% of the rotating residents and interns over the study period and 20 TPs who participated [Table 1] and [Table 2]. The 10% of the residents were excluded because they were unable to be scheduled due to their busy schedule. All participants filled the assigned questionnaire form.
Table 1: Demographics of trainees (n=30)

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Table 2: Demographics of teaching physicians (n=20)

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The data was analysed based on two sample responses in a separate way, and then, comparison was conducted by using t-test statistics.

Phase 1

We analysed the residents' sample of the study regarding their perception about benefits of BT in non-clinical shift in terms of clinical knowledge, data gathering, procedure, communication and feedback. The grand mean responses of the resident sample (4.63) indicated that the overall sample responses strongly agreed that BT has a variety of benefits [Table 3].
Table 3: Residents' perception regarding the benefits of bedside teaching in teaching shift

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The most important elements that show benefits to the trainees include encouraging the residents to ask questions and actively participate, allowing motivation and facilitating self-learning. The average mean of the sample response was 4.55.

The overall residents' response indicated that BT greatly affects their clinical knowledge, with a grand mean of their response reaching 4.58; this is mainly achieved by encouraging development of a learning plan and emphasising what is important to remember, as the mean value for the sample responses reached 4.63–4.68, respectively [Table 4].
Table 4: Residents' perception regarding the benefits of bedside teaching on clinical knowledge improvement

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Most of residents who participated in this current study, strongly agreed that the BT has significant effects on data gathering, with a grand mean value of 4.73 [Table 5].
Table 5: Residents' perception regarding benefits of bedside teaching regarding data gathering (history and physical examination)

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The most important impact of BT on data gathering was represented by residents' ability to identify and prioritise critical, emergent and less urgent conditions. It also helped them to develop differential diagnosis as well as allowing them to take proper detailed history, with a mean value of 4.83.

Regarding the procedures, most of the residents did not get a chance to perform any procedure. Hence, 16 learners were not able to comment on the benefit of BT on procedure performance. On the other hand, those who had a chance to perform a procedure (45% of the sample) agreed on the benefits giving a mean value of 4.93 [Table 6].
Table 6: Residents' perceptions regarding the benefits of bedside teaching on procedures

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If we compare the results of the trainees' and the TPs' responses regarding the procedure performance, we noticed that only 4 (20%) of TPs agreed about the benefits of this teaching modality, where as in the trainees group, 14 (45%) agreed.

The reason behind this discrepancy was because, in some sessions, there was more than one learner but not more than three learners at the same time.

The overall responses of the sample of the study agreed that BT has some effect on communication, particularly in providing fair interaction with the TP and ability to gather data from the patient freely with mean value of 4.8 and 4.7, respectively [Table 7].
Table 7: Residents' perceptions regarding the benefits of bedside teaching in communication

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Most of the residents strongly agreed on the positive effect of constructive feedback with grand mean value of 4.58 [Table 8].
Table 8: Residents' perception regarding bedside teaching benefits on constructive feedback

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Moreover, we noticed the most important effect of giving feedback was when the learner received formative feedback and when the learner was able to give feedback about the session with mean values of 4.79 and 4.57, respectively.

The overall sample perception confirmed that they agree that this teaching modality has so many benefits; this is supported by grand mean value of 4.69 [Table 9]. This was achieved mainly by learning a lot from the session; meeting the residents' expectations by having relevance to their learning objectives; and further enhancement by the feedback received during the session with mean values ranging from 4.79 to 4.93.
Table 9: Residents' perception regarding overall impression about benefits of bedside teaching

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Phase 2

In this phase, we analysed TPs perception regarding BT in non-clinical shift regarding the same benefits.

We observed that the grand mean value of the TPs' responses was 4.76, indicating TPs strongly agreed that it has great effect on teaching, particularly regarding enabling the TP to collaborate with the learner about what should be covered and enables them to make efficient use of time, with both having a mean value of 4.85 [Table 10].
Table 10: Teaching physicians' perception regarding the benefits of bedside teaching in non-clinical shift

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In addition to that, the TPs highly believed that these sessions could be conducted based on educational objectives with minimal external interruption with mean values of 4.7 and 4.65, respectively.

Regarding the effect on improvement of clinical knowledge, the feedback was very positive and supported by grand mean of 4.41 [Table 11].
Table 11: Teaching physicians' perception regarding bedside teaching in non-clinical shift in clinical knowledge

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On the other hand, it was clearly noticed that the overall sample responses strongly confirmed a significant effect on data gathering with grand mean value of 4.3 [Table 12].
Table 12: Teaching physicians' perception regarding the benefits of bedside teaching in data gathering (history and physical examination)

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Based on the TPs' perception on the role of BT in improving data gathering, it is observed significantly in giving the patient adequate time to tell about his/her illness in his/her own words, able to perform logical sequences of physical examination as well as demonstrate the patients' consideration during the interview. This is supported by mean values of 4.4, 4.4, and 4.3, respectively.

However, it has limited effect on procedures, as 80% of the responses indicated that it was not available in contrast to only 20% who strongly agreed [Table 13].
Table 13: Teaching physicians' perception regarding bedside teaching in non-clinical shift benefits on procedures

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The most important effect of this modality was reflected by the ability of the learner to show concern about the patient problem, introduce him/herself to the patient, taking the patient consent as well as having a fair interaction with the TP, with mean values ranging from 4.2-4.45 [Table 14].
Table 14: Teaching physicians' perception regarding bedside teaching in non-clinical shift benefits in the communication

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Most of TPs strongly agreed that it is very effective in providing feedback, supported by a grand mean value of 4.57 [Table 15].
Table 15: Teaching physicians' perception regarding bedside teaching in non-clinical shift effect on providing feedback

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The overall impression of TPs was positive as they mostly strongly agreed in their overall responses (70%) [Table 16].
Table 16: Teaching physicians' overall impression

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Phase 3

We compared means of the results from both groups by t-test and P > 0.05.

The results of t-test do not detect significant variations between the perceptions of the two study samples regarding the benefits of BT in non-clinical shifts, t-value range of -2.65-2.14 [Table 17].
Table 17: T-test to examine significant variation between samples perceptions

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In fact, it confirmed that the majority of residents and TPs strongly agreed about its benefits.

The same was observed about the P value; it did not show any statistically significant value, except for data gathering, 0.04.

The open-ended questions were excluded from the analysis as most of the participants left it unanswered.


  Discussion Top


BT is considered one of the most useful and important educational modalities in the medical profession, but it is still underutilised.[6],[16]

On the other hand, another qualitative study based on a focus group discussion [16] showed the best values of BT in different areas as:

  • Obtaining a medical history
  • Performing a physical examination
  • Generating a differential diagnosis
  • Formulating a management plan
  • Applying clinical reasoning
  • Communicating effectively
  • Exhibiting professional bedside manners
  • Demonstrating empathy
  • Performing diagnostic and therapeutic procedures.


However, the most common barriers were frequent interruptions, time constraints and lack of preparedness before the sessions.[16],[17]

Most of the publications about BT were focussing on the benefits and barriers of this clinical educational modality, which might limit its utilisation, so we tried to overcome some barriers of BT in emergency room, where there are frequent interruptions and unpredictable situations. We planned a schedule for non-clinical shift parallel to clinical schedule, and we focused on postgraduate learners, residents and interns.

To evaluate the impact of BT in non-clinical shift, we used questions focusing on the following five main domains considering the perception of the two groups (TP and trainees): data gathering, clinical knowledge, procedures performance, communication skills and constructive feedback.

Based on our data analysis, we found that the study confirmed that BT has a variety of benefits, which helped them deal with the time constraint concern in the non-clinical shift. In addition, the results discovered that the most important features that show the benefits of BT for residents include encouraging residents to participate actively, allow motivation, and facilitate self-learning.

Our study confirmed what was addressed previously, that the learners and teachers believed BT to be effective for learning communication, history-taking, and physical examination skills.[16]

Regarding the benefits of BT in clinical knowledge, the study has shown that the most important signs of effects of BT on clinical knowledge are through covering knowledge about specific topics and the emphasis of what is important to remember. However, most of the sample responses indicated that they strongly agree that BT effects on clinical knowledge could be seen in covering general broad knowledge and allowing applications of evidence-based practice.

Concerning the benefits of BT on data gathering, the study revealed that most of the trainees strongly agreed that BT has significant effects on data gathering, particularly in identifying and prioritising critical, emergent and less urgent conditions. However, even though the TPs agreed on the benefits of BT on data gathering, it was to a lesser extent.

Regarding BT effects on the procedural skills, either in performing diagnostic and therapeutic procedures or in performing adequate supervision and guidance during performance of the procedures, majority of the participants were not able to comment due to inadequacy of performing procedures.

BT has clear positive effects on constructive feedback. In contrast to what has been done before, the benefit of feedback effect was evaluated from the learners' perspective only as the teacher was giving feedback to learner but not receiving any feedback about his/her performance as a teacher.[4]

In our study, we found that availability of enough time gives both (TP and trainee), a chance to give a two-way constructive feedback about their performances besides overall opinion about the session and get suggestions for improvement.

The study confirmed that TP responses strongly agreed that BT provides sufficient benefits for TS; particularly because it enables TP to collaborate with the learners about what should be covered and also enables to make efficient use of time.

The study also revealed that BT has good effects on communication; in particular, it provides fair interaction with the TP and the trainee, and they can gather data from the patient freely with minimal or no interruption. It was reported in the literature that BT improved patients' satisfaction as the patients have better understanding for his/her disease when the discussion takes place at the bedside.[6]

The study concluded that there is no significant variation between the perception of trainees and physicians regarding the benefits of BT in non-clinical shifts; both groups of participants strongly agreed on the benefits of BT on clinical knowledge, data gathering, communication and constructive feedback, with minimal or no effect on the procedure performance. The BT is still a valuable teaching modality despite the availability of new education modalities.[6]

Limitations of the study

The main limitation of this study is the small sample, location in just one training centre and the self-reported nature of the data collection.

The other main limitation is the availability of participants. To get participants who are willing to come in on his/her off time and prepare educational materials might be challenging in the absence of incentives.

Patients' acceptance for this type of teaching is also another challenge for both the learner and the TP.


  Conclusion Top


BT in a non-clinical shift is very effective to improve the learners' clinical knowledge, communication skills and to facilitate giving constructive feedback as well as data gathering.

However, the benefits on procedural performance need to be further investigated.

Recommendations

It is recommended to create a well-organised BT programme for the residency curriculum as well as students.

Acknowledgement

I gratefully acknowledge the Chairman and all the staff in the ED at King Abdulaziz Medical City, for participating in this study as well as all the staff in the Medical Education Department, particularly Professor S. Obenshain and Dr. Amir Omair, for their continuous guidance and priceless advice.

Special thanks to Dr. Maram Al-Hubayshi for her valuable contribution in data collection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Ramani S, Orlander JD, Strunin L, Barber TW. Whither bedside teaching? A focus-group study of clinical teachers. Acad Med 2003;78:384-90.  Back to cited text no. 5
    
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Peters M, Ten Cate O. Bedside Teaching in Medical Education: A Literature Review. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24049043. [Last accessed on 2013 Sep 19].  Back to cited text no. 6
    
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Craig S. Direct observation of clinical practice in emergency medicine education. Acad Emerg Med 2011;18:60-7.  Back to cited text no. 15
    
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Wenrich MD, Jackson MB, Ajam KS, Wolfhagen IH, Ramsey PG, Scherpbier AJ. Teachers as learners: The effect of bedside teaching on the clinical skills of clinician-teachers. Acad Med 2011;86:846-52.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17]



 

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