Bedside Teaching in Neurology

Jeffrey J. Dewey, MD, MA; Tracey A. Cho, MD

Disclosures

Semin Neurol. 2018;38(4):441-444. 

In This Article

Abstract and Introduction

Abstract

The patient's bedside offers an ideal venue for teaching the art of clinical neurology and modeling humanism and professionalism. However, bedside teaching is underutilized in modern medical education, despite evidence that learners desire more. Logistical challenges and lack of teacher confidence are commonly cited reasons, but both can be mitigated with a deliberate approach and sufficient experience. Well-executed bedside teaching can provide lasting lessons for learners while enhancing the patient experience, without affecting the efficiency or quality care delivery. In this review, we discuss the theory and evidence to support the use of bedside teaching, and subsequently delineate a framework for designing and executing effective bedside teaching in neurology.

Introduction

Though popularized in modern medicine by Osler, the tradition of bedside teaching dates back to the late Middle Ages[1] and was later championed by Sylvius in the 17th century, who wrote:

"My method, hitherto unknown here, and possibly anywhere else, [is to] lead my students by the hand to the practice of medicine, taking them every day to see patients in the public hospital, that they may hear the patients' symptoms and see their physical findings. Then I question the students as to what they have noted in the patients and about their thoughts and perceptions regarding the causes of the illnesses and the principles of treatment. [2]"

In his groundbreaking report on American medical education, Abraham Flexner also frequently emphasized the importance of learning through supervised experience with a patient.[3]

The art of neurologic reasoning through careful history taking and skilled examination is particularly well suited to being taught at the bedside. Jerome Posner has been quoted as saying, "Different from all other medical specialties, save perhaps psychiatry, the neurologist is heavily dependent on listening to and interpreting what the patient tells us… If you don't know what is happening by the time you get to the feet you are in real trouble."[4] Though the perceived difficulty of this art has been cited as a contributor to what Jozefowicz coined neurophobia among medical students,[5] the epiphany students experienced from seeing clinical neurology in action can show them the joy in this challenge and draw them to the specialty.[6]

Throughout medical education, however, the practice of bedside teaching has become increasingly scarce. Although 50 years ago up to 75% of medical teaching took place at the bedside,[7] current estimates place this number between 8 and 19%.[8] Numerous obstacles to bedside teaching have been cited, most commonly concerns over the patient experience and logistical challenges associated with the modern healthcare environment.[7,9–15] Yet, the bedside is considered by teachers and learners alike to be an effective locale for teaching the history, physical exam, and humanistic aspects of medicine.[8,15–24] Moreover, most patients and families feel positively about being involved in bedside teaching.[25–27]

Bedside teaching has previously been defined broadly as "clinical teaching in the presence of a patient,"[8] which must be distinguished from "door-jamb" or "corridor" teaching.[28] Many conceivable clinical settings can fit this definition of bedside teaching, including brief demonstrations of exam findings, supervised clinical encounters, precepted clinics in the ambulatory setting, or full case presentations to a team in the presence of an admitted patient as part of daily rounding (i.e., traditional "bedside rounds"). Similarly, there is no single method of effective bedside teaching, though similar behaviors tend to be identified across numerous qualitative studies.[11,15,16,20,29–31] At the core of all bedside teaching is the collaboration of teacher, learner, and patient with the common goal of improving care for the patient and—through building the learner's knowledge and skills—the care of future patients. Thus, regardless of setting or style, the characteristics of an effective bedside encounter are universal.

In this review, we will discuss the theoretical foundations of bedside teaching and review the limited evidence available to support its use. We will then identify best practices in bedside teaching and review challenges to effective practice and techniques for mitigating these challenges. Finally, we will address the patient dynamic in bedside teaching, with special attention to patient-centered teaching.

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