Article review: Bedside teaching in the ED

Bedside teaching is a unique educational skill, which academic faculty are often assumed to just know how to do. In the ED, it is especially difficult to do this well, because of crowding and unexpected time-sensitive clinical issues, which create distractions and general chaos. Experientially, unpredictable clinical issues negatively impact bedside teaching. Thus, faculty should be flexible and knowledgeable of basic bedside teaching tenets.

A good friend of mine, Dr. Mike Gisondi (Associate Program Director at Northwestern) co-authored this much-needed faculty development review paper on bedside teaching in Academic Emergency Medicine in 2006. Mike was the resident on my very first shift as a faculty member at SF General! I was fresh out of residency and lucked out having Mike on shift with me.

The authors provide 10 building-block strategies to improve your bedside teaching:

1. Plan the teaching session BEFORE the shift. Select a few teaching points on common chief complaints or classic high-risk conditions. I often focus on either (1) first-trimester bleeding or (2) walking the learner through central line placement using a sample kit. Takeadvantage of any free moment to do a little quick teaching.
   
2. Know one’s team and their goals. Are your learners senior medical students? Pediatric interns? Family practice residents? Senior EM residents? Asking them what they’d like to learn more about for that one shift guarantees more learning buy-in from your team members. For instance, I have noticed that our pediatric interns want to learn more about wound closure such as suturing, stapling, and tissue adhesives. So I keep a lookout for laceration cases for them.
3. Choose the right time to teach. Don’t feel like you have to be teaching all the time. Obviously, acutely ill patients requiring immediate medical attention should trump bedside teaching. Having the learner observe your actions and interactions, however, is still a valuable observational learning period. Whether you realize it or not, you are teaching. For more stable patients, you can preview patients’ chief complaints in the triage notes and pre-plan your 1-minute teaching session while the learners are seeing the patients.
4. Set realistic expectations for yourself. Start slow. Pick only 2-3 topics to teach each day. For example, pulmonary embolism and aortic dissection should be at least briefly considered in all chest pain patients. With more experience, you will become more comfortable and efficient with bedside teaching, and your bedside teaching repertoire will naturally expand.
5. Limit the amount of time with each patient. You don’t have to teach every medical concept for each patient. Let’s be realistic! Pick 1 concept and discuss a little more in-depth. This is a crucial strategy to remember. Teaching 1 concept well is much better than glossing over 5 concepts, overwhelming the learner, and slowing down the ED flow.
6. Be professional.
7. Use the Socratic method with caution (if the patient is present). Making the learner look bad in front of the patient may negatively impact the patient-physician relationship for the learner. If you use the Socratic method, try to ask questions of other team members in the room – not the actual primary provider.
8. Summarize and evaluate. After each patient case, summarize what the learner has learned to solidify the educational process. Also, don’t forget to give feedback to the learner at the end of shift. This is a form of teaching also.
9. The “teach-only” attending. Because the clinical pressures in the ED constantly are at odds with bedside teaching time, some institutions have a teaching attending. This faculty member’s sole responsibility is to teach learners. S/he has no clinical responsibilities that day. This teach-only attending can do bedside teaching, give 5-15 minute didactics, and/or teach a brief procedural workshop. This attending can also observe learners and provide immediate feedback on their clinical skills, professionalism, and efficiency.
10. Train residents how to teach at the bedside. Having senior residents as near-peer teachers has been shown to be extremely effective in an Internal Medicine clerkship. I can’t wait to have UCSF-SFGH EM senior residents! We are currently recruiting our third class in our 4-year program.

Reference:

Aldeen AZ, Gisondi MA. Bedside teaching in the emergency department. Acad Emerg Med. 2006 Aug;13(8):860-6.

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